Bob Simpson’s essay “Cultural Diversity: Walking the biomedical tightrope” highlights the diversity of the NHS multicultural alliance and provides an excellent metaphor to understand a clinician’s daily dance during each patient encounter. He uses tight-rope walking to frame the balance a clinician attempts when situating a medical condition in the reductionist, standardized medical framework and simultaneously within the patient’s individual intersection of biology and biography. For medical educators like myself, this balance between the medical and the personal is a critical concept taught to build the skills that create a compassionate clinician. Bob Simpson rightly calls in dominant demographics in healthcare environments to reflect and explore the ontological assumptions that inform and guide their daily practice of medicine.
This type of reflection bolsters compassionate communication on an individual patient-doctor level, but also forms the basis of an intentional anti-racist healthcare system. For example, Ibram X. Kendi’s excellent “How to be an antiracist” calls out individuals to explore their most deeply held, often implicitly held, beliefs and assumptions to form a just and equitable society. Kendi challenged his readers to do the work to identify the racial assumptions, implicit and explicit, that guide themselves, in order to transcend the divisions in our society. Physicians learn this skillset and can be powerful agents for change. In another example, John Rich M.D.’s book “Wrong Place, Wrong Time” contains case studies that recount the real-life experiences of young black men whose lives are peppered with violence and his honest, insightful, and informed reflections about the racist societal perceptions that young men bring on the violence themselves. Dr. Rich’s book shows how stories are important, validation of experience is important, that being heard is crucial to healing, and that a therapeutic relationship requires work be done by both sides to find a common goal. I see clear parallels with the tenets of antiracism as posited by Ibram X. Kendi. The work Simpson highlights, of deep self-reflection and open deep listening to the lived experiences of others, without taking personal offense or reacting with defensiveness, can thus serve multilayered goals.
How do these ideas lay out in the clinic? The fourth wave of Covid-19 in the United States has triggered a new crisis in healthcare – an erosion of empathy by healthcare workers for the unvaccinated. The overwhelming majority of patients now hospitalized with Covid-19 are admitting to being unvaccinated despite the marked increase in cases of the delta variant. Healthcare workers are struggling to find compassion for them through their fatigue and anger. The rapidly growing gulf between these biographic and biologic groups – the vaccinated healthcare workers trying to provide care and unvaccinated patients needing medical care – exemplifies a novel flavor of bias based on assumptions that fail to incorporate the world view on both sides. The doctors and nurses who have largely accepted full vaccination as an outreach of their professional identities just cannot find a way to understand the unvaccinated. My concern is that the gulf in understanding leads to patterns of healthcare that exclude patients who are making choices that are misunderstood by providers. There is clearly a large group of Americans whose ontological views that are premised on factors such as distrust of the health system, distrust of government regulations, and sinister conspiracy theories have made the notion of vaccination undesirable.
This current situation has me thinking of other incidences in which healthcare has blamed patients for their medical conditions: gun violence against young black men, type 2 diabetes in obese patients, hypertension and renal failure in black patients, HIV infection in gay men, hepatitis C in IV drug users. The horror of dealing with a catastrophic new wave of illness combined with an available prevention strategy may make it hard to overcome anger and grief to listen to the stories of these patients. Becoming offended by a public that openly distrusts the healthcare worker’s own logic and decision-making suggests that bias-driven assumptions are over-riding compassion, closing the minds of the healthcare workers. The contempt reported in social and traditional media mirrors the discourse heard in some sociopolitical circles surrounding racism and inequality. Bad medical care takes the form of inadequate care of hypertension, renal failure and diabetes in impoverished or minority communities by wealthy white physicians who do not explore the root causes of those illnesses. Racism takes the form of perpetuation of poverty by wealthy homeowners who restrict affordable housing in their neighborhood, but also the calls heard in the US last year for doctors to “stay in their lane” when Emergency Room doctors spoke up on social media against gun violence. Not listening to the stories and understanding of the root causes in lived experiences lead to chronic illnesses precipitated by socioeconomic factors. Those socioeconomic factors have structural causes, and both can be changed by one and the same reflective process of learning the stories of people unlike oneself. The best physicians are masters at this skill.
A question in this moment of the Covid-19 pandemic is how clinicians might learn and understand why their afflicted patients declined vaccination. That understanding might help to save a patient, but also the next patient in the community by building trust through authentic compassion. It is by building the bridges that healthcare will move a reticent patient to become vaccinated against Covid, and a system to invest in and value its misunderstood or disadvantaged members. The tenets of clinical interviewing are to ask open ended questions as much as possible, and then to listen deeply. Tips and tricks in medical interviewing include to avoid personal assumptions, to ask for feedback about patient values at each decision point, and to not weigh options according to one’s own values or beliefs. Once the patient understands that the physician is willing to do the work to meet the patient on their own terms, and their individual situation, a relationship to build health can begin. Obvious representation in the form of a diverse healthcare workforce is a crucial first step to elevate a variety of life experiences, but I would argue is insufficient when there will always be some form of underrepresented groups. Kendi and others have asked individuals in dominant demographic groups to acknowledge that bias is inherent to humans, including physicians. Self-reflection by compassionate physicians confirms that bias impacts patient care and professional life, but that awareness of differing ontological frameworks can breed conversations, conversations breed empathy, and empathy is the basis of compassion which is a willingness to act. Being willing to act on behalf of another defines both the effective physician and the antiracist.
Simpson, B. Cultural Diversity: Walking the Biomedical Tightrope. The Polyphony. August 21, 2021. Cultural Diversity: Walking the Biomedical Tightrope – the polyphony. Accessed 8/27/21.
Kendi, I. How to be an Antiracist. One World Publishing. 2019
Olewaida N, Joseph J, Glover A, Paz H, Gray H. Making Anti-Racism A Core Value In Academic Medicine. Health Affairs Blog. 2020, Aug 25.
Rich J. Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Men. Johns Hopkins University Press. 2011
Lara Ronan, M.D. FAAN is an academic Neurologist and Neuro-Oncologist with an interest in the medical humanities and narrative medicine. She is currently the Assistant Dean of Student Affairs, Diversity, Equity, and Inclusion at Drexel University College of Medicine. She was a 2019 Public Voices Fellow of the OpEd Project at Dartmouth College and has published a number of essays and opinion pieces on doctoring. Follow Lara on Twitter @lara_ronan.