Written by: Antoinette N. Jones, MD, MS
In a time when it seems all the world is trying to right itself up during a pandemic and so much social unrest, the subject of racism in medicine is even more difficult to ignore. I find the terms moral distress and moral residue gives me the language to more clearly express some of these difficult topics and has empowered me. Moral distress, initially defined by Andrew Jameton in 1984, happens when a person recognizes a moral problem but is constrained from acting on it or finding a way to resolve it. As medical trainees, we regularly find ourselves present for some of the most vulnerable times in the lives of our patients and their families. Unfortunately, that also means that we can find ourselves in the middle of encounters where not all participants are conducting themselves well. More often than not, we remain calm, deferentially diffuse the situation, but struggle with how it makes us feel for hours and sometimes even days or weeks afterward.
The practice of medicine regularly involves making life-and-death decisions for our patients and aiming to do so in an ethical manner, which often means that emotions are high. We are routinely expected to face these times of great conflict unwaveringly. As trainees, we can grapple with feelings of powerlessness or inadequacy. To make matters worse, practicing physicians from racial and ethnic minority backgrounds often confront racism and bias from peers and superiors as well as from the patients they serve. Racism in medicine is not often discussed, and thus, interventions to address it are lacking.
As a black physician, I often find myself trying to strike a balance between moral outrage and advocacy, but sometimes there is a fatigue that comes with the responsibility of being that representative. This moral distress is not likely to be unique to me. How do we begin to face these issues in a productive manner? As a medical trainee and a member of the Gold Humanism Honor Society (GHHS), I do believe that it is important for us to have a voice and to speak up during these challenging times.
We know that black Americans comprise 13% of the U.S. population, and make up only 4% of the 877,000+ active physician workforce. Black female doctors represent only 2% of physicians. It is important to consider that this lack of representation has repercussions that reverberate throughout all aspects of medicine, whether it is medical education, the practice of medicine or medical outcomes. How can the GHHS be productive and supportive during this time of unrest? How can we build our capacity for empathy towards each other, with a focus on supporting black physicians who are dealing with racism as well as trauma and sadness at all levels of training?
Firstly, I believe that we should acknowledge that a problem exists. Racism and medical racism is a real problem. We should proceed by being both open and available for communication. We should recognize that we all have biases as a consequence of being human, and are obligated to address them at an individual as well as a societal level. Social determinants of health are conditions in the environments in which people are born, live, learn, and work. The medical field has long recognized that these social determinants do affect health, functioning, and quality-of-life outcomes. The facts are undeniable. Black women are more than three times likely to die of pregnancy-related causes than their Caucasian counterparts. The Black infant mortality rate rivals those of some under-resourced nations, and is more than twice as high as the infant mortality rate of whites. Perhaps it is time to recognize that these disparities are not simply a consequence of race itself, but rather institutionalized racism. Perhaps the fact that these socioeconomic factors are so intricately intertwined only serves to underscore the importance of the need for social change.
Your doctor can be young.
Your doctor can be black.
Your doctor can be a woman.
Your doctor can be from Brooklyn, NY.
Your doctor can be a young black woman from Brooklyn, NY.
Medicine is rarely about right and wrong answers. Even in unimaginable situations there are blessings and moments of gratitude to be focused on. We can hold both. In medicine, limitations exist and loss sometimes occur. It is not good versus bad or about choosing a side. The concept of holding both helps us recognize that we cannot control every outcome (and we try not to dwell on that fact), but where we can advocate or intervene and improve the training of physicians as well as improve health disparities, we are obligated to do so. If we are holding both, we would say, there is suffering but there is also healing, and one is not a failure of the other. There is inequity, but there is hope. We are looking forward to change for the better. As members of the GHHS, we aim to practice medicine in a humanistic and ethical manner with a compassionate outlook. Racism is a public health crisis. We must strive for justice. We must aim for peace. We must not remain neutral because it is that neutrality that leaves us with decades of data showing us that health disparities among racial lines are not improving sufficiently. At an institutional level, we ought to be brave enough to ask the right questions and be actively anti-racist. We must not stop until these inequities are rectified.
During this particular time of great unrest and sharing our truths, we should aim to recognize that everyone has a story and everyone has certainties and uncertainties. Recognizing that when faced with difficult decisions, holding both will make us more compassionate and effective physicians. We work neither for them nor us, but for both, and consequentially, for all.
- Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall; 1984.
- Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330-342.
- Xu JQ, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2018. NCHS Data Brief, no 355. Hyattsville, MD: National Center for Health Statistics. 2020.
- Ely DM, Driscoll AK. Infant mortality in the United States, 2017: Data from the period linked birth/infant death file. National Vital Statistics Reports, vol 68 no 10. Hyattsville, MD: National Center for Health Statistics. 2019.
- Acosta D, Ackerman-Barger K. Breaking the silence: time to talk about race and racism. Acad Med. 2017; 92(3): 285-288. doi: 10.1097/ACM.0000000000001416.