How Long Are You Going to Keep Your Mouth Closed? (Part 2)

They Deserve So Much Better: Compounded Trauma While Training

I’m writing this in frustration and helplessness after another long day of watching underrepresented medical residents struggle in plain sight from race-based trauma.

It was 10:10 pm. I’d just put my youngest to bed after a long day of meetings, patient care, more meetings, and parental responsibilities. I meticulously completed my patient documentation, then internally celebrated the moment I could finally go to bed. I was exhausted. Prompted to check my email one last time, I opened my laptop and found this message:

Dr. Ilodi,

Do you have time tomorrow to chat? I am having some issues in my residency program, and I would like your advice.

Of course, I responded. I’m always happy to talk. Stop by my office tomorrow morning.

I closed my warm computer, my anticipation of sleep interrupted with worry.

I thought about common issues of the past and wondered which one would rear its head the next day:  racial discrimination, gender discrimination, microaggressions, or microinvalidations? Any one of those would have been a good guess.

As the diversity, equity, and inclusion officer for two institutions, learners of color often request my support for residency program meetings that may be disciplinary in nature. Other times, they use my office as a safe space, free from the burdens of work responsibilities and social “-isms.” When they settle into a seat in my office, I hear about the microaggressions, microinvalidations, and blatant racism they encounter each day in the medical ward or outpatient clinic. The insults might come from anywhere: patients, peers, attendees, or nurses. Enough of these interactions can cause emotional and psychological distress known as race-related trauma. By the end of their residency training, you can see the effects of such trauma. Those who entered the program bright-eyed and full of confidence and optimism often finish emotionally weathered, socially isolated, and mentally exhausted from the brutally of not having the space to be authentic.

A 1995 study by D.C. Baldwin Jr. et. al. revealed minority physicians were almost 30% more likely to withdraw from residency or take an extended leave of absence than their white counterparts. In 2006, J.M. Liebschutz et.al. studied 19 Black residents and reported training experiences characterized by pervasive discrimination, lower expectations from supervisors, harsher consequences for mistakes, and social isolation. In 2018, Aba Osseo-Asare, MD illustrated that minority residents routinely experience racial bias at work, but they’re reluctant to report it to the appropriate authorities. That same study found residency programs generally lack institutionalized systems that promote diversity; instead, they rely on minority students to fulfill these tasks, because, you know, they don’t have enough to do already.

At this time, I will use the phrase “historically excluded in medicine” instead of “underrepresented in medicine.” The latter expression omits the reasons we are under-represented in medicine. As a mentor to these students, residents, and fellow physicians, I am concerned for their mental and emotional wellbeing.  In July, when the new trainees start, they are eager to care for patients, make friends their colleagues, and learn from their superiors. However, like the Midwest in October, when the leaves have transformed from a lush green to dry multi-colored hues, resident physicians of color begin to show weariness.  The complexities of anti-Black racism are far-reaching, and medical professionals of color are not exempt. Beginning at training and throughout their careers, they are often left out of conversations, professional development, and relationships that build connectedness, which leads to anxiety, depression, and a decrease in concentration and focus, ultimately affecting their performance. They juggle this while balancing their professional lives, personal identities, and emotional wellbeing while caring for medically fragile patients. Think about how they must feel, dealing with all of this while patients count on them to be at their best.

People in the medical field are extraordinary. They spend more years in school than most, and sometimes they save lives. Faced with almost impossible circumstances, they keep going, believing what they have to offer improves the quality of life for countless patients. This is a heavy weight to bear, made heavier by microaggressions and insensitivity. Historically excluded students receive lower than average evaluations than other residents, with vague reasoning, and constantly feel the need to persuade the observers that they belong in a white coat. They do all this while attempting to disprove media stereotypes, working twice as hard to get half the credit in their respective programs. People think doctors have hit the professional jackpot, but the Black Tax exists here, too.

Still, this is their life’s calling, so they stay and do whatever they must to survive. Under racial distress, learners of color work harder and smile wider in the name of resilience. To fit in, they shoulder the burden of racism in silence and stuff down the feelings that come with it, a vicious emotional and psychological cycle that exacerbates race-related trauma.

I met with my medical learners to see how I can help them. My guess was right; discrimination had struck again. Even in the safe space of my office, some were silent (or speechless?), and others pretended it didn’t affect them. Still, others expressed profound stress that had begun to show up physically and psychologically in the form of inattention, stomach pains, fatigue, and headaches. But they needed to be resilient, so they’d been suffering in silence. Understanding this torture rack, I continue to make myself available, dig deep, and pay it forward.

I’m privileged to know many determined and hardworking residents and fellows. Through four or more years of undergraduate studies, four years of medical students, and mixtures of graduate programs, I’ve learned the value of resilience. Some of my colleagues are from war-torn countries with little resources, some are published, some are non-traditional, some are in their second career. I value all of them. However, I know they don’t feel valued in the field, and I know this because I asked.

I briefly interviewed some of the historically excluded residents, and these were their thoughts:

1.     “I feel like I’m not given the benefit of the doubt compared to our peers all the time, and I don’t feel supported by faculty who bully others in a professional setting.”

2.     “I’ve been racially profiled while practicing medicine while Black.”

3.     “Professional bullying.”

4.     “Chief called me in because there were complaints, but when I asked for specific examples, he couldn’t give us any.”

5.     “I’m forced to repeat rotations when there are complaints.”

6.     “When I’ve met with program directors, they just give lukewarm responses or shrug.”

Black people in America have struggled against a power construct since the White Lion, a privateer boat, brought the first 20 Africans to America to make them slaves. Today, 400 years later, you can hardly turn on a screen without seeing images of protests, BLM hashtags, or cops in riot gear. It got so bad in 2020, millions all over the world joined in to protest police brutality that disproportionately occurs in Black communities. On May 25 of that year, George Floyd’s murder was captured on video. Former officer Derrick Chauvin knelt on Floyd’s neck for 8 minutes and 46 seconds, choking him to death in broad daylight. Other high-profile murders by police that year, namely those of Ahmaud Arbery and Breonna Taylor, contributed to the decline in mental health and morale of my learners of color. Some of them became silent and withdrawn while others became more anxious. Of course, I had allies at my institutions who rallied for changed and requested to be educated, but they could do that themselves; I focused my attention on our depleted URM learners. Their baseline experience is daily doses of racism from folks in the building and the institution itself. Add internationally-broadcast murders of Black and Brown bodies and a pandemic that was taking thousands of lives each day, many in their own communities, and you get demoralized learners of colors who still have to go to work when they’d rather hide under the covers for days and try to catch their breath. But they kept showing up, trying to pull their best from deep within their stomachs, pretending to be unaffected.

My interest in mentorship through recruitment, equity, and inclusion coincided with my first year of residency in 2008. I was one of three URM internal medical residents out of around 90 residents in the program. I was lonely, isolated, and scared, and deeply desired advocacy and inclusion. In my three years as a resident, I found no support, so in 2012, as a geriatric attendant, I wanted to lend my amateur support services to underrepresented minority students, residents, and fellows. Since then, through mentally taxing and physically demanding experience, I’ve created support services that include mentorship, group support, and advocacy. Additionally, recruitment initiatives via pipeline programs and community outreach have been implemented at my institutions. While it’s progress, it’s certainly not enough.

Race-based trauma can elicit responses comparable to PTSD. In response to the stress of the medical professionals I serve, I’ve become obsessed with advocating for their well-being, even to the detriment of my own. I’ll keep going, but I can’t do it alone. Here is what medical education could do to ease the burden:

1.     Release a specific statement that acknowledges the complexities of educating a diverse community of learners.

2.     Truthfully and openly acknowledge structural racism as a public health crisis because it creates mental and physical health disparities.

3.     Create safe spaces and support teams for house staff to discuss their concerns.

4.     Support strategies to safely unite house staff with the community to dismantle structural racism.

5.     Advocate for feedback and improvement tactics.

6.     Encourage resident committees that want to make positive change within the hospital or in their program.

7.     Establish a formal, standardized reporting system for racial bullying that utilizes a chain of command.

8.     Educate on microaggression and how to prevent racial profiling and inappropriate behavior in the workplace.

9.     Involve the program directors and encourage them to have open conversations.

10.  Acknowledge the experiences of URM residents. They aren’t making things up or overreacting.

11.  Listen.

This broken system can be fixed, and it doesn’t have to take forever. What we need are leaders who care as much about the professionals doing the heavy lifting as they do about stakeholders and those who might be offended. But because progress is slow in this country, especially as it relates to people of color, I’ll keep on pushing until we make some headway.

Good thing I have good vitamins.

Sources:

·      Olayiwola, J. Nwando. The Annals of Family Medicine. May 2016, 14 (3) 267-269; DOI: https://doi.org/10.1370/afm.1932.