july 2020, Volume XXXIV, Number 4
Institutional racism in medicine
It’s time for changes
nstitutional or systemic racism is defined as “the distribution of resources, power, and opportunity in our society to benefit white people and the exclusion of people of color.” Present-day racism is built on a long history of racially distributed resources. It’s a system that comes with a broad range of policies that keep it in place and is present in every element of society, including health care.
To elucidate and address many of these issues, members of the Minnesota Association of African-American Physicians (MAAAP) have contributed their perspectives to this article, including a handful of personal experiences. These world-class professionals join me in this commentary to address what remains America’s single biggest unsolved challenge.
A historical perspective
Before the Civil War, very few Blacks graduated from American medical schools—perhaps fewer than two dozen. Most Black doctors at that time learned through apprenticeship. Despite their scarcity, the benefits of Black doctors treating Black patients were already evident, both in terms of Black doctors better understanding medical issues prevalent among Black Americans and in their being more receptive to treating members of the Black community.
After the war, opportunities began developing for Black students, almost exclusively male, to attend medical school. Established in 1867, the Howard University College of Medicine was the first all-Black medical school. By 1910, a survey of medical schools known as “The Flexner Report” identified over 150 medical schools nationwide, including Black-only medical schools.
The Flexner Report was intended to standardize medical education and increase physicians’ quality in the United States. Despite good intentions, it was a document with implications for African-Americans, leading to the closing of historically Black medical schools, leaving just two in the nation. African-Americans were excluded from the institution of medicine, leaving Blacks vulnerable to institutional abuses in health that facilitated distrust and disenfranchisement.
Blacks were forced to form their own medical organizations.
The lack of trust among Blacks for the American health system was substantiated over time by unscrupulous research, such as the use of cervical cancer cells from Henrietta Lacks without permission after her death; the Tuskegee Study, where Black men were told they were being treated for syphilis, but actually, they were not, so the researches could document the natural course and destruction of the disease; Dr. J. Marion Sims, a 19th-century physician, who conducted brutal gynecologic surgery on enslaved Back women without anesthesia to “perfect his surgical techniques”; and many other projects that have treated Black Americans disrespectfully and even inhumanely.
While the 14th Amendment presumably established racial equality in 1868, it did not address discrimination, segregation, or many of the fundamental seeds of racism. For instance, White medical schools had no directive to accept Black students, and few did.
In 1896, the Supreme Court’s Plessy v. Ferguson decision upheld the racist concept of “separate but equal.” Segregation of public schools was not found unconstitutional for another half-century in the 1954 Brown v. Board of Education decision that itself took over 15 years to take full effect. These past actions on society established institutional racism in every sector, and health care was not immune.
Blacks were forced to form their own medical organizations, such as the National Medical Association, when prevented from joining White organizations, namely the American Medical Association. The cover of the first journal of the National Medical Association, in 1909, clearly stated: “Conceived in no spirit of racial exclusiveness, fostering no ethnic antagonism, but born of the exigencies of the American environment.” Even today, the challenges that influence whether Black students matriculate or apply to a medical school program remain multifaceted. They include financial cost, bias and stereotypes, imagery and career attractiveness, and underperforming precursor schools. Statistical trends confirm our nation’s inability to attract and sustain a diverse physician workforce. When the Flexner Report was released in 1910, Black doctors’ proportion to the Black population in the United States was 2.5%. In 2019 it was 5.0%. The most current data at the University of Minnesota Medical School for 2020 shows 3% Black enrollment.
From institutional to personal—Dr. Zeke McKinney
For health care workers, discrimination is still prevalent. One thing in particular that remains a problem is placing Black or underrepresented professionals in positions of authority. While it is appreciated and admirable for employers to address issues of diversity and inclusion, it sends an inverted message when the time and energy required to manifest these intentions is not allocated.
Unfortunately, this same degree of obtuseness can exist in terms of understanding the context in which underrepresented minorities can experience discrimination with respect to their workplace performance. Underrepresented individuals may be seen as “oppositional” in workplace interactions when speaking up, even when they do so appropriately. The latitude offered others—such as not being disciplined when frequently late—may not be offered to minority employees.
Even outside of workplace performance, social interactions for underrepresented individuals that intersect with workplace culture can be challenging. For example, there is a common practice of workplace teams going out for “happy hour” meetings. This can result in excluding those with religious beliefs that include abstaining from alcohol.
Discrimination remains a prevalent problem.
Additionally, many underrepresented professionals (including myself) almost always dress extremely professionally, always wearing a tie or dress shoes. I had experienced several independent instances where workplace colleagues saw me outside of work, when I was dressed in street clothes, and heard “Wow! I didn’t recognize you; you look like a thug (or hood or gangster).”
Lastly, a common challenge remains in how Blacks and other underrepresented populations fear or hesitate to engage institutional structures. This hesitation also exists in the area of bringing about those concerns to leadership when they arise.
A double-edged sword?—Dr. Dionne Hart
My home is Chicago, one of the most segregated cities in the world, so I have personal experience with racism. Yet I honestly believed racism would not be overt in health care.
That changed when my brother Michael died of complications from an aortic dissection. After collapsing at work, Michael waited for hours in an emergency department with classic signs. After an excruciating wait, he was sent home by providers who determined he likely had a kidney stone. While preparing for a follow-up primary care appointment, Michael died from cardiac tamponade. When his heart stopped, he fell with only a towel around him as if he’d just stepped out of the shower.
Michaels’ death led to me leave Chicago to train at the Mayo Clinic. I committed myself to becoming one of the best physicians, one who would never make such a serious misdiagnosis as the one that led to my brother’s untimely death.
Although my overall experience as a resident was outstanding, there were dark moments. For example, I would be mistaken for the interpreter or directed to leave a patient’s room because visitors were not permitted after hours.
I had also been told by a colleague that they felt threatened when I shared a critical statistic about an African American woman whose case was left out of a presentation. As an attending physician with authority, I have encountered other experiences that were not mere professional slights, but “blows to the gut” that made me feel helpless and hopeless.
On my first day on call as an attending physician, a nurse told me she was so happy I was on staff and “tickled pink” that I spoke English. I learned to live with such microaggressions to avoid retaliation until things got out of hand.
My supervisor threw objects at me during rounds, regularly yelled at me, and reportedly called me an n-word b**** in my absence, telling others she did not know how to “control” me. While the administration never told me directly what had happened, a union representative informed me of the incident. She was never again my supervisor, and although temporarily relocated to a different office, she was suddenly back working in the same building as me without notice. After years of dealing with constant harassment, the message communicated was loud and clear: my feelings and experience were not valued.
I continue to explain to well-meaning White colleagues that racism still exists, is systemic, and impacts them. I have grown tired of justifying my experience as a Black woman, as a mother of two Black men, and as a professional. There is no current or future cultural competency course that will change someone’s heart—and we need to change hearts.
A systemic issue—Dr. Charles Crutchfield
As a senior medical student, I did a surgical rotation at a southern institution with a large hospital. On one occasion, I assisted on a parathyroidectomy, and as I was leaving the operating room, one of the nurses came up to me abruptly. She wagged her finger in anger and said, “This is the last time I’m going to tell you this. Pay attention to the corners!”
I had no idea what she was talking about, and I was utterly dumbfounded. At the end of the case, the surgeon said everything had gone very well, telling me, “Thank you for your help. Nice job.” I wondered, “Why would a nurse criticize me when the surgeon did not?” Did parathyroidectomy involve “corners” that I didn’t do correctly?
Returning to the main locker room, I passed two more operating rooms, one with a janitorial crew of two African American men and two Hispanic men, all wearing surgical scrub suits. One of them was methodically mopping the corners. It hit me like a brick: my skin color led the nurse to assume I could not have been part of the surgical team. I became so enraged that my face felt as if it was on fire. I went to find her to let her know that I was a medical student and part of the surgical team. Thankfully, I did not find her, as I would have said something that would have gotten me in big trouble.
Racism is a culture shock—Dr. Inell Rosario
Throughout my education, classroom professors often had a difficult time distinguishing me from another Black female student, even though we had no significant resemblance. I also did not expect the continuing parade of racially offensive encounters I would face over time, even as a medical student. For instance, after scrubbing for a case during my residency, the attending surgeon and I waited for drying towels. He was given a towel, but I was asked why I was just standing there and instructed that the garbage was in the corner. On another occasion, a woman at a restaurant assumed I attended community college. When I said I did not, she told me that it was never too late to get an excellent education. I chose not to clarify that I was already a medical doctor.
We need to change hearts.
I also painfully recall going for a second opinion to a local facility with my mother-in-law, who had been recently diagnosed with mantle cell lymphoma. The physician walked in, saw five family members, read an erroneous note on my mother-in-law’s chart indicating she did not speak English, and said, “Oh no, not another one to slow down my day.” I reassured him that we all spoke English and would translate for her. That was the only time I ever threw out the “I’m a doctor” card, but it made no difference. He never apologized or changed his attitude toward us.
Because of my upbringing and faith, these incidents have not rocked my self-confidence or made me bitter. Even amid current racial unrest, I’m confident we will move forward. There are many good people of all races, and we need to create the narrative. Character, capability, and chemistry have no color.
Overall I see myself as a doctor who also happens to be a Black woman. I want to treat patients of all ethnicities and see their differences only in a manner that allows me to connect with them to provide patient-centered care. I will continue to do my part in educating my colleagues so that we enable all physicians to take care of all patients irrespective of color.
Where are the black health care executives?—Dr. Tamiko Foster
It is not for lack of capable and qualified individuals that so few African Americans hold positions as executives and on boards of health insurance companies, health systems, and hospitals. An unwelcoming and dismissive culture contributes to qualified professionals from underrepresented populations often hesitating to bring concerns to management or seek leadership positions within dysfunctional institutional structures. A culture that fails to address these systemic issues—which could be done in many simple ways—only perpetuates them.
I remember it as if it were yesterday: “This is Dr. Morgan. She is my boss now.” These were the words of the company’s former chief medical officer, a White male who introduced me to the group of health care C-Suite executives I would be working with. His stern introduction appeared to be some sort of rite of passage.
As I took my seat at the table of White men, most at least 20 years my senior, the voices of welcome were drowned out by the daunting realization of loneliness that accompanies leadership as an African American. The reality of seeing and realizing how few people who looked like me in these leadership spaces was inevitable.
Disparities in health care leadership and governance opportunities have been attributed mainly to racial discrimination and bias. While African Americans and other non-Whites have increasingly gained a seat at the table in diversity and inclusion positions, their presence in top leadership positions in health care organizations, such as the C-suite, boards of directors, and senior management, is lacking. For the few who do attain such positions, their voices are often silent due to fear of an unjust backlash that comes from failing to conform. They have the title without the power and the pressure to work twice as hard to be respected.
My skin color led the nurse to assume I could not have been part of the surgical team.
I had the painful experience of backlash from a trusted mentor after a promotion. The promotion was not worth the daily microaggressions and attempts at sabotage, but I stood strong. Others have been passed up for promotions, commonly described in the minority community as the classic case of “training and doing the work for the inexperienced White male colleague who received the promotion.” White privilege acts as a pass that grants those who are part of an informal network unique opportunities but leaves others feeling left out.
During my career, several African American leaders have shared their stories of being labeled as “unsociable,” “unfriendly,” or “overly sensitive” when their participation in a system that has been socialized as being right is questioned. It’s a heavy burden to feel that your performance is judged at a microscopic level based on your skin color. This is what White privilege and racism in the workplace looks like.
It’s disheartening to see organizational charts full of faces in leadership who don’t look like you. Recruitment and retention for African Americans and other non-Whites in these positions need to be strengthened. This happens best through policies put in place and enforced rather than being left to chance. Like many, I felt confident in my ability to do the job when given the opportunity and the resources to succeed. Sadly, this opportunity is not granted for most due to the color of their skin.
An unprecedented moment?—Dr. David Hamlar and Mary Tate
Black men were counted as two-thirds of an American citizen under the Constitution. The Civil War nearly destroyed the Union. We endured the Jim Crow era, countless lynchings, and riots in the 1960s and the 1990s—and we continue to see racial inequality and disparities in all facets of American life. None of these events was considered “unprecedented,” so why is this moment any different?
We continue to struggle to enroll underrepresented students in our medical schools, to demand equal access to medical care through programs such as the Affordable Care Act, and to seek funding for clinics and hospitals in communities of color that are patient-centered and culturally sensitive. Despite all of the barriers, Minnesotans of color have managed to find a way to survive, but at the cost of nation-leading health disparities.
By any other name, this is systemic racism, which has led recently to street protests involving all demographics. Black people are underrepresented in the composition of CEOs of area hospitals, Fortune 500 companies, the state government, and within the police departments themselves. By holding them all accountable in this moment of recognition, admitting that systemic racism exists, and working toward the engagement of White America, we can make a real effort to change.
As a start, we must 1) construct health care systems and medical school policies, practices, and procedures from an anti-racism lens and implement accountable policies, practices, and procedures; and 2) make real change through actions that are intentional, measurable, sustainable, and reflect the institution’s visions, mission, and guiding principles.
Changes to make a real change
To make real change the actions must be intentional, measurable, sustainable, and embedded in the institution’s visions, mission, and guiding principles. We must require health care corporate leaders and executives, as well as those in academia, to take a deep look and dive on why and how to implement systemic change. We must construct health care systems and medical school policies, practice from an anti-racism lens, and implement accountable action. Some areas to address first include:
Requiring Predominantly White Institutions (PWI) to recruit, matriculate, hire, and retain Black students, staff, and faculty and create safe spaces for Black individuals to be supported and thrive in these environments.
Providing opportunities to mentor Blacks and offer role models.
Investing in pipeline programs.
Teaching about health disparities within the medical school curriculum.
Preparing all students to work in diverse health care systems and communities.
Teaching future physicians on how to be culturally competent and anti-racist.
Requiring institutional leaders and others within the academic setting to take an in-depth look and dive into why and how to implement systemic change.
Many additional changes are needed. This article has focused on issues faced by Black physicians, but structural racism extends from here into population health through a number of avenues that include government policy, community access, and reimbursement. These issues are as complex and deeply embedded as the ones we have discussed and we will explore them further in a follow-up article next month.
The term “institutional racism” was first coined in 1967 by Stokely Carmichael and Charles V. Hamilton in “Black Power: The Politics of Liberation.” They wrote that while individual racism is often identifiable because of its overt nature, institutional racism is less perceptible because of its “less overt, far more subtle” nature.
Institutional racism is a form of racism embedded as normal practice within society. It leads to discrimination in criminal justice, employment, political power, and education. It is present in health care where we are all taught Primum non nocere (“First do no harm).
Addressing the issues discussed in this article will help foster a new generation of Black physicians and health care industry leaders. We are committed to that new generation and the people they serve of all races having a better, more equitable future than experienced today or by any generation before.
The following health care professionals contributed to this article:
Charles E. Crutchfield III, MD, Clinical Professor of Dermatology, University of Minnesota Medical School, Immediate Past President of the Minnesota Association of African-American Physicians, and Medical Director at Crutchfield Dermatology.
Tamiko Foster, MD, MPH, Corporate Medical Director at Centene Corporation.
David Hamlar MD, DDS, Assistant Professor in the Department of Otolaryngology, Head and Neck Surgery, at the University of Minnesota.
Dionne Hart, MD, President of the Minnesota Association of African-American Physicians.
Zeke J. McKinney, MD, MHI, MPH, FACOEM, Faculty Physician, HealthPartners Occupational, and Environmental Medicine Residency.
Inell Rosario, MD, Otolaryngologist with Andros ENT & Sleep Center.
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