A Call for Action Against Racism in Medicine

“I remember when Philando Castile died, it was during my first week as a faculty member,” recalls Krys Foster, MD, MPH, Clinical Assistant Professor in the Department of Family and Community Medicine. “I just wasn’t at my best. One of the residents came up to me and said – I understand that today is a hard day for you. It was a small gesture, but it was an acknowledgement of the pain physicians of color so often carry unnoticed.”

It’s a pain that was triggered yet again last summer, with the murder of George Floyd at the hands of police. His death sparked national outrage and a widespread movement for racial justice, all occurring against the backdrop of COVID-19, which has disproportionately impacted communities of color. The combination of these public health crises has compelled the conversation about race and health disparities. As these conversations unfolded, Dr. Foster and some of her colleagues on the Society of Teachers of Family Medicine Minority and Multicultural Health Collaborative began emailing back and forth, creating a virtual space to commiserate and vent about their own experiences as Black, indigenous, and people of color (BIPOC) physicians and as allies­—being on the frontlines of two different pandemics that are killing people of color, bearing witness to how years of racism in medicine has and continues to impact both patient care and physician well-being, and carrying the weight of batting these injustices. Eventually those emails turned into an open letter to the medical community, published in Annals of Family Medicine this week. Here we talk to Dr. Foster about the letter, her experiences, ally-ship, and her hopes for change.

What compelled you and your colleagues to write this essay? Why was it important to write it in this current moment?

We have our annual Society of Teachers of Family Medicine meeting in the late spring and last year it got pushed because of COVID-19. This is usually our one opportunity to get together each year—it’s a huge source of support and fellowship, especially for those of us who come from underrepresented minorities. We were already lacking that connection, and then with George Floyd’s death, we felt we needed it more than ever. We started connecting virtually, and the more we talked, the more we felt we needed to put down what we were feeling into words.

While it is encouraging to see that academic and medical institutions are taking a stance and putting anti-racism at the forefront, something we all felt frustrated by was the lack of substantive action. As the protests over the summer died down, much of the rhetoric felt performative, especially on social media with the black squares and hashtags. At the same time, many of us, as the few BIPOC physicians in the room, were feeling the weight of being asked by our leadership and colleagues—what do we do? We know that this question is well-intentioned and they want to help, but it does put undue burden on those of us who are underrepresented in medicine. We are being asked to fix problems that we, as the oppressed group, are the primary targets of, and we don’t have all the answers. So in writing this piece, we felt that maybe we can unload some of the emotional burden that we've been carrying. It was cathartic. But we also wanted to provide some actionable steps that can hopefully answer some of the questions we’re constantly being asked, and act as a blueprint for allies.

I wanted to ask about how the phrase “We are tired” is echoed throughout the essay—it was really powerful. Why was it important for all of you to express that refrain?

In our exchanges over the summer, we all expressed feeling so fatigued, personally and professionally. We’re juggling different roles in our lives—many of us are parents, caregivers, educators and leaders at our institutions who have been fighting this fight for so long. It is exhausting to cope with all these layers of mental duress- physician burnout, fearing for our family’s well-being, and the racial trauma of seeing our communities being brutalized by police. I'm a junior faculty member, so I can't say that I've been doing it for as long as some of my colleagues, but even being in medicine for less than 10 years, I feel this heaviness already.

Part of the burden you carry, as you explain in the essay, is the “minority tax” – can you break down what that looks like?

The “minority tax” is the extra burden of responsibilities placed on minority faculty, whether it be minority race, ethnicity, gender, sexuality, in the name of achieving diversity and inclusion. But those efforts are not compensated, and don’t necessarily result in promotion or tenure. As doctors, our mission is one of service, so we take on these additional tasks because we want to be advocates for our respective, often vulnerable, communities. But then to see that your colleagues who don’t face the same kind of barriers that delay your own promotion reach that finish line first, that’s upsetting. It’s exasperating to be asked to lead different committees or justice groups and do all this work that we can’t list on our CV’s, on top of all the work we do as physicians and educators. Furthermore, the tax can be multiplied—being a Black, female physician, it’s a constant battle.

We talk about the “minority tax” in the essay so that folks can understand the kind of impact it has on us, and just acknowledge that our experience as underrepresented minorities is different. We’re not asking others to do our jobs for us, but sometimes I wish my role didn’t have to exist.

What do you mean by that?

I’m the only Black attending physician in my practice, and the Chair of our Social justice, Inclusion and Health Equity committee. I'm the one in the corner advocating for underrepresented groups. In match meetings for our residency program, I see applicants who may be from underrepresented backgrounds and may not have a long list of accolades. And I understand what the barriers might have been for them. I understand the bias in recommendation letters. I understand the bias in navigating the hierarchy of medicine as a medical student who is from a minority background. And so, because I see and understand that, I'm the one who has to speak up. Or I'm working with staff in the office who are primarily Black or Latinx, and a micro-aggression may occur but it may go unnoticed. And so then I have to say something and I feel like it kind of falls to me because otherwise, no one else sees it as their responsibility. I wish it didn't have to be like that. I think we're going to learn and we're going to do better and hopefully these micro-aggressions will no longer be an issue in the workplace. But for right now, I’m the person who has to put her neck out to advocate for individuals who may feel they don't have a voice - that's the minority tax. I wish I didn't have to pay it, I wish it didn't have to be me. I wish someone else, who is in the majority, would do it. And that's what this letter is asking.

There have been several instances over the last year of BIPOC doctors being asked by their institutions to lead discussions on race and inequities in medicine, and then getting backlash or even losing their jobs…

It is really frustrating. On the one hand, BIPOC voices are being amplified and elevated to these platforms, but then the idea that we could be punished for that - it’s not only a dangerous form of gas-lighting, but it will have lasting repercussions on credibility and employability. One doctor was suspended and is undergoing an investigation – that’s going to be a mark on their career forever. I'm fearful that that's going to happen more and more now that institutions are starting to have these conversations, and many underrepresented minorities are being asked to step into the limelight. Essentially, BIPOC academic physicians are being thrust into these positions without the full backing of organizations, and the assurance that jobs are safe. Without that protection, we’re going to lose talented physicians because they feel like they can’t risk speaking out, nor can they sustain a career in an environment that doesn’t feel welcoming. I’m concerned that we’re already seeing an exodus of Black physicians from academic medicine.

Are you ever worried that the letter will receive backlash?

I can’t speak for everyone in the group, but it's definitely something that I’ve thought about. Knowing that this will be listed in my first-author publications, I do fear repercussions. Particularly as a Black female, there’s always that concern of being perceived or targeted as the “angry Black woman,” and we were very purposeful that this letter not come off that way.

The letter is titled “Dear White People” - how do you hope your white colleagues will react to this letter?

We wanted this paper to be collegial, and to recruit allies with whom we can think collaboratively about solutions to racism and inequities in medicine. In the letter, we talk about the complexities of navigating white fragility – in fact, writing this essay was an exercise in that. As we do in our daily walks as physicians, we chose to tread lightly with our words and not to point blame. This letter is to examine and dismantle systemic policies and practices—it’s really a call to action. There’s a line in the essay— “We refuse to move into this new sociopolitical moment continuing to have our fellow minority colleagues bear the sole responsibility for change.” This is to say, we are at a tipping point, and we are pleading, literally begging you—our white colleagues—to act now in solidarity, because it’s been far too long.

In choosing the title, we really wanted to emphasize that while we can do a lot of the work, our voices cannot be lifted up until the majority is ready and willing to help. My hope is that individuals in leadership positions think deliberately about how their decisions uniquely impact BIPOC, particularly given the historical inequities in medicine towards these communities. I hope they consider how they can use their position to elevate BIPOC physicians without putting undue work on them. I hope it gets our leaders to really think about what their mission and vision are for their departments to create a culture that's safe for those individuals.

In the essay, we provide a list of specific actions for our white colleagues who want to be allies - and in order to truly be an ally, you have to walk that walk daily, you need to question yourself, you need to read, you need to be thoughtful in your actions and decisions, acknowledge your privilege and be accountable for your mistakes. In writing the letter, we were really intentional about modeling ally-ship and lifting underrepresented voices up—for instance, not all of my co-authors were underrepresented minorities. They also supported me, as a Black junior faculty member, in taking lead authorship.

What do you hope this essay does for the BIPOC medical community?

I hope it provides them a PDF that they can forward to their leaders when they’re asked—what should we do? (laughter) No, but in all seriousness, I hope that they hear that they're not alone.

You and your colleagues write in the essay about the enormous racial disparities in COVID and the way it has impacted Black, brown and indigenous communities—can you speak to your experience on the frontlines and witnessing that disparity in real time?

It's really been hard to watch. I'm not surprised, but it's been hard to watch. While there have been significant developments in telehealth, drive-thru testing and online test results—communities of color may not have the same access to those resources. Some of my patients are essential workers, and I have to tell them ‘You cannot go to work today, you need to quarantine and isolate” and they tell me – ‘Who is going to support my family?’ I’ve had patients hide their test results so they can still get a paycheck, some don’t have the space to isolate from their other family members. And ultimately, I’ve had to see so many people from my community lose their lives to this virus. Now with the vaccine coming out, these vulnerable communities need it the most but because of the way the medical system has exploited them in the past, there’s naturally this mistrust and they don’t want to take it. How do we rebuild that trust?

That was going be my next question—what would be your message to communities of color about the vaccine?

As a scientist and as a physician, I absolutely value the work that's gone into creating the vaccines. I've actually now received both doses of the vaccine. But I understand why people may not trust the process, and I think it's appropriate to question the safety of the vaccine. I think at a time when it's crucial to support our communities that are the hardest hit by COVID-19, it's important for us to do our due diligence and really seek evidence in order to make a sound decision that's right for you and your family. Don’t go by hearsay or things you see on social media. Speak to your doctor, and someone that you trust to understand why you feel the way you may feel about the vaccine, and come up with an action plan for how you might acquire reliable and accurate information. I personally have family members and patients who say that they're not going to get the vaccine and I'm hurt by that, but I don’t fault them. All I can do is listen with an empathetic ear, not dismiss their concerns, make sure I've done my job in sharing what I think the benefits are, and give them my recommendation.

It does feel like there is a widespread reckoning around the issue of race and racial justice – why do you think this movement took off the way it did?

That's a question that I've asked myself a lot—what’s different now? Why is George Floyd different than any of the other individuals who've been murdered? I can think of a couple of reasons. George Floyd’s murder happened at the height of the first wave of the pandemic. The nation was hurting, and I think that was the tipping point. The other reason, unlike some of the other murders, he was literally killed on camera, with bystanders who did not act. You cannot hide that. And finally, I think because of social media, so many people were sparked to action. But I truly don’t know why this triggered so many people to act, I’ve asked myself that question a lot. Because every life mattered. What about all the others? And what about the others that are coming after this? The system hasn’t changed.

Do you think it’s going to be different this time around?

(A long pause) I have to hope so. In conversations with my colleagues who have been in this fight for longer than I’ve been, I know that these movements go through ups and downs. We know that this work is long and hard, but I'm hoping that we are going to ride this wave of policy change and anti-racist education. I'm hopeful that there will be tools to create meaningful, sustainable change to continue on this upward path. I can only hope.