Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Chief Complaint: Racism


Patients are increasingly recognizing the impact of racism on their health. We should be prepared to help patients confront this and consider this core to our work to systemically address this public health crisis.

My patient listed off a litany of his life stressors and then summed it by saying, “It’s the racism, doc—the racism is making me depressed.”


His eyes searched mine for a response, but my tongue was heavy.


With increasing frequency, patients are discussing the pain of being racialized in America. Native American patients are discussing the burdens of historical trauma and painful family histories. Pediatric patients present with the hurt and anguish of being racial outsiders demonstrated by name calling and other negative behaviors by their peers.


I went into medicine because I wanted to help people, particularly the underserved and marginalized communities like the ones I grew up in. I imagined myself partnering with patients and communities to improve health outcomes. I wanted to work with Black and Brown patients because those were the people who needed me the most.


While in medical school, we were taught about race and health in a one-dimensional way. Race was a factor tagged onto the epidemiology of diseases. Black people were at risk for a myriad of conditions, like premature labor, hypertension, diabetes, and early death from cancer, heart attacks, and stroke. Could it be the poor diet, poor lifestyle habits, obesity, or the ubiquitous “socioeconomic status” that caused these outcomes? Though not explicitly stated, one could easily draw the conclusion that Black people were somehow defective, something was missing in their community, their culture, maybe even their genes. I concluded the fixes were increasing access to quality care and health education.


But actually practicing medicine in America changed me. Health is more complex than what I was taught in lectures and textbooks. The vast majority of what could make my patients healthy are outside of my control and much is outside of theirs. Education, food security, and economics broadly determines who gets achieves and maintains health and who doesn’t. What determines who has access to these keys to health? Racism is an unspoken factor in the health of many of my patients.


What if during medical school someone told me I could predict my patient’s life expectancy by looking up their zip code and skin color? I suspect I would have been saddened, overwhelmed, and questioned the utility of stuffing my head with pathophysiology and antimicrobials. But that despair would have led the way to an earlier awareness and preparation to get to the root of our health problems. It’s the work all of us must do to truly serve patients and communities.


We must start by:


1. Affirming the experiences of patients who want to discuss the health consequences of racism with you and acknowledge its invisible impact on all patients, especially those from Black and Indigenous populations.


2. Identifying and addressing disparities in health outcomes in our clinics.


3. Evaluating and eliminating individual and systemic bias in the policies and practices that drive who we recruit and select as students, trainees, and attendings at our institution.


4. Doing the collaborative work to build anti-racist and equitable communities.


The work can’t be distilled into an algorithm. Reflection and active commitment from all disciplines and levels in healthcare hierarchy is required. Engaging racism as an upstream determinant of health is the foundational work necessary to eliminate the stubborn health disparities that continue to afflict the most vulnerable in our country.