Our complicit role in systemic racism

Bad data

It is clear that Canada has a diversity problem in medicine, which is compounded by the fact that we simply don’t collect good data. Our best estimates in medical school programs suggest that some groups—East and South Asians—are overrepresented relative to their population and that Black and Indigenous people remain woefully underrepresented.¹ That’s not to say there has been no movement. Many universities have made special efforts to recruit Black and Indigenous students. But critics correctly point out that is only a tiny part of the answer. Until we address other disparities seemingly unconnected to medical school admissions, we won’t correct the gap. For example, suspension rates in kindergarten to grade 12 school boards are disproportionately higher for Black and Indigenous students.^2,3 At the risk of stating the obvious, a history of suspension is not typical of most matriculating medical students. In an episode of incredible irony, I had an argument recently with a senior colleague who insisted that it was actually white men who were most disadvantaged in the medical school admissions process, despite objective data to the contrary. Even (and perhaps especially) for those who think they don’t see race, unconscious bias makes admissions committee members more likely to select students whose race reflects their own.⁴

But what about so-called model minorities? If East and South Asians are relatively overrepresented, surely, they have nothing to complain about, right? This myth of hardworking, scientifically minded Asians belies a truth that is much more complicated. To begin, there is an implied belief—including by my aforementioned colleague—that these students are taking spots in programs that would have rightfully gone to white students.⁵ Somehow the default remains that others are “taking away” from the dominant group—with the message that white students are actually the most deserving. Once in medicine, their presence in the field might not translate to leadership roles. This is known as the bamboo ceiling,⁶ and its effect is amplified for women.

Occupational citizenship

Personally, the most damaging feeling is an unrelenting message that I don’t belong. I am not white, and as such, I am asked incessantly to explain my brown skin. The questions range from shocking to snide. I am asked where I am from, where I graduated, if I know that Muslim person in town, why my English is “perfect,” whether I speak Hindu, what I think about honour killings, where I do yoga, whether I plan to stay in Canada, and the best Indian restaurants, stores, cookbooks, movies, and vacations. The truth is that it doesn’t matter whether people mean well. The effect is that I am repeatedly made aware that my position both as a physician and a Canadian is tenuous at best. This reflects what one researcher terms occupational citizenship,⁷ where access to the privileges of physicianhood are tied to service to the “real” citizenry. My legitimacy as a physician depends on cheerfully answering questions about my background and expressing my gratitude for being able to live in Canada. These could also be considered microaggressions, which are small often unconscious forms of bias that are not a big deal individually but have substantial cumulative effects. In my case, it has contributed to feelings of burnout.

It turns out my experience is not unique. In one study of Black, Latino, and Native American residents, researchers found that they too faced frequent microaggressions. They were asked to be racial ambassadors and felt “othered” in the workplace.⁸ Put another way, they felt dehumanized. Residents and trainees are in a particularly vulnerable position, and it would be understandable that they would not always feel safe to bring up issues of race.⁹

We know phenomena like burnout are related to these feelings of depersonalization.¹⁰ Non-white physicians are subject to experiencing these feelings just as white physicians are, but they face being dehumanized themselves, which is an added burden of racism. In fact, a 2019 study showed that anti-Black racial bias was more pronounced among non-Black medical trainees in periods of increased burnout.¹¹ Interestingly, a popular conclusion in the media coverage of that paper was that we should reduce burnout to reduce bias. Little if any attention was given to the possible effects on those experiencing bias, and how that might contribute to their experiences of burnout, job performance, and satisfaction.

Pass the mic

I confess that I am a little scared about how people will respond to this essay, much more so than content I’ve written previously. Race makes us uncomfortable, but that’s part of how racism persists—we just never talk about it. I once read a quote that captures my feelings about race precisely: you don’t need to be a voice for the voiceless, just pass them the mic. But in medicine, taking the mic to speak out can have real negative consequences, and I have experienced them personally. Nonetheless, I am not Black and I am not a trainee and as such I have less to lose than other physicians, so here we are. My experience is mine alone, and the studies I’ve cited only scratch the surface. If you look around your department, clinic, or training program and it doesn’t reflect the racial makeup of our population, then maybe it’s a good opportunity to ask why. If the answer is uncomfortable, you might need to pass the mic.