Truly addressing health disparities and racial justice requires an intense and challenging examination of our own clinical practices and how they may perpetuate inequalities. We must continually hold ourselves and our institutions accountable on the path to building a more just medicine.
“Dad had a parole violation . . . shooting across the street last week . . . he punched a hole in the wall . . . might get evicted . . . teachers say meds aren’t working.”
So often, these are fragments I scribble during 30-minute “med check” visits. A child with disruptive behavior and his parent see me every month, exhausted or frustrated, sad or scared, and articulate a tangled web of psychiatric symptoms, psychosocial challenges, traumas, and injustices. A mother plays a phone message from a teacher, cataloging an event that cleared an elementary school classroom of its students, insisting that I make a change. I check the clock and see how little time we have left in our appointment and my anxiety starts to swell. I feel incompetent and unhelpful. Nothing I’m doing is working and so I have to try something different. I inquire about the timing of the outbursts, I double check medication adherence, and I look at the treatment history. I have three minutes left in my visit. Mom agrees to a stimulant change after I attempt to explain why, after a brief description of pharmacokinetics, “maybe this one will work.” They both leave and will follow up next month. I breathe a little easier. I did something.
When I was a child psychiatry trainee, the temptation to “just do something,” was immense. As of 2018, there were 18 different methylphenidate preparations to treat ADHD and 57 different available unit dose forms. A prescriber who resolves to “do something” each month can theoretically last more than four years before exhausting just one of the two distinct stimulant chemical entities.
Since graduating, I’ve spent the last three years seeing kids and families, mostly Black, through community-based treatment models in some of Baltimore’s most disadvantaged neighborhoods. In traveling to schools and visiting homes, I don’t need to jot down notes describing deeply segregated neighborhoods overwhelmed by violence, apartments neglected by landlords, and families torn apart by mass incarceration—I see it with my own eyes in a way I never could from the office.
In the community, I sometimes feel just as desperate and helpless as I did as a trainee and the urge to “do something,” in order to relieve my own anxiety, occasionally reemerges. As I’ve come to understand the extent to which the symptoms my pediatric patients experience are generated and exacerbated by psychosocial issues that our society openly chooses not to address, making a tweak to stimulant and scheduling an appointment for next month no longer alleviates that discomfort, and the illusion that a new prescription will help has evaporated. The medical jargon that conveys authority loses its potency and there’s no white coat to hide inside. My patients and their families probably always knew that “maybe this one will work” was an insult to all of us, but now it’s finally obvious to me.
I still write prescriptions and change medications, but now I attend a lot of Individualized Education Program (IEP) meetings at schools, write letters to utility companies, and make sure there’s food in refrigerators. I try to leverage a fancy degree to push against institutions, and I also share some of the anxiety, anger, and despair that my patients and families feel simply because of their zip code and skin color. I try to tolerate my own discomfort enough to try to understand the lived experience of my patients and their families.
As the COVID-19 pandemic disproportionately rages in communities of color, and the murders of George Floyd and many others spark uprisings and protests across the U.S., the structural inequalities wrought by white supremacy and the health disparities they produce are now finally nakedly apparent. Many university presidents and medical department leaders have sent letters declaring that “we stand in solidarity with our African-American patients and colleagues.” We may even go one step further, taking the Implicit Association Test or glancing at anti-racist bibliographies in order to feel like we’ve “done something,” and then return to our overwhelming professional lives.
These gestures are not unimportant, but they are wholly insufficient unless we undergo an arduous and uncomfortable self-examination into how we contribute to the perpetuation of the disparities that brought us to this overdue boiling point.
Feeling uncomfortable, however, cannot be the end goal and medicine cannot self-flagellate away its failure to address health disparities. We cannot heal what we do not understand and we cannot understand what we refuse to see. Our institutions need to fully and continually reckon with how they may have treated Black bodies as disposable and Black neighborhoods as cheap development opportunities. Medical education must include community voices and community critique and resist the temptation to exalt our profession and ignore its failures and abuses. As academic medical centers depend on and benefit from the patients that come from the communities in which they are situated, those same institutions must do better to ensure that those who train, treat, research, and lead come from those same neighborhoods. The clinical care for our Black patients must acknowledge their racial and cultural identities and its centrality to their lives and we must continually interrogate, assess, and adjust our practices if we aspire to actually be better doctors and alleviate the conditions that led our Black patients to see us. Anything short of this is no different from switching from one stimulant to the other to get to the next appointment, in which the only relief is our own.
Suggested reading or listening: “The Black Plague, by
Suggested viewing: Documentary on Cultural Humility. “Cultural humility” is an inquisitive process by which we can understand others’ experiences and address power imbalances in the patient-physician dynamic. By Drs. Melanie Tervalon and Jann Murray-Garcia.