Podcast

Sound Mind: Racism in medicine

June 1, 2021

Dr. Kenneth Fung, clinical director of the Asian Initiative in Mental Health at Toronto Western Hospital, and Dr. Joseph Mpalirwa, family physician at Toronto’s Casey House and co-author of a recent study on Black physicians’ experiences of racism, talk about racism in medical culture, why it persists and how it affects physicians, residents and medical students.

“Racism can occur in so many different contexts. For physicians, it’s highly demoralizing and puts us at risk of burnout when we face patient encounters that are racist in nature, and then find ourselves in a system that we don’t feel part of – or are oppressed in some way.” – Dr. Kenneth Fung

From being mistaken for an orderly, being asked to speak English in a staff room or being passed over for leadership positions, Black, Indigenous and physicians of color have many experiences of racism in medical culture.

In this episode, Dr. Kenneth Fung, psychiatrist and clinical director of the Asian Initiative in Mental Health at Toronto Western Hospital, and Dr. Joseph Mpalirwa, family physician and co-author of the new study “Patients, Pride, and Prejudice: Exploring Black Ontarian Physicians’ Experiences of Racism and Discrimination”, talk to Dr. Caroline Gérin-Lajoie about the impacts of racism in medicine on physicians, residents and medical students and the ways it can affect their wellness.

This episode is available in English only.

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Topics

Equity and diversity in medicine Organizational wellness

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Dr. Caroline Gérin-Lajoie (Intro): Welcome to Sound Mind, a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin-Lajoie.

Here in Canada, a public recognition of the harms caused by racism and discrimination is slowly taking place. Many organizations are now attempting to address the impacts of systemic racism on minority and marginalized populations. And within medicine, many hospitals, medical schools and other institutions are working to repair and rebuild. But what about the impacts of racism on physicians themselves? And more specifically, how may it be affecting their wellness?

My two guests have both considered the ways in which racism affects medical professionals. In today's podcast, we hope to amplify their voices in a discussion on how equity, diversity, inclusion and physician wellness intersect.

Dr. Kenneth Fung is an award winning psychiatrist and clinical director of the Asian Initiative in Mental Health at Toronto Western Hospital. Dr. Joseph Mpalirwa is a family physician and inpatient physician at Toronto's Casey's House and recently co-authored a published study on black physicians experiences of racism and discrimination in Ontario. Hello and welcome to you both.

Dr. Kenneth Fung: Thank you for having me here.

Dr. Joseph Mpalirwa: Yeah. Thanks for thanks for having me.

Dr. Caroline Gérin-Lajoie: I am joining you as a white Francophone female physician, and my goal is to listen, to learn so that through this conversation and others on the topic of racism and discrimination, I can become more aware and hopefully become a better ally. So I want to start by asking you both a basic question, where do you think the medical community is at right now when it comes to addressing racism within the profession? Joseph, let's start with you.

Dr. Joseph Mpalirwa: I think we have a very long way to go. I think we are hopefully at a moment of reckoning, like much of the rest of the world. The conversation on racism and even more specifically on anti-black racism has really gained some traction, even specifically in medicine, even in comparison to the time that I was a medical student and resident, which wasn't too long ago. It's no longer acceptable to be quiet or to be on the fence when it comes to talking about racism and racism in medicine. I'm cautiously optimistic that the conversations are starting to happen because, you know, history has taught me that a lot of the time it can be all talk. And we've often been stalled by the fact that medicine is is painted as this altruistic, noble, honorable profession, forgetting that medicine is built on such heinous acts of racial violence that we don't often acknowledge.

But I am starting to see some small steps in the right direction, initiatives that are putting that talk into action. But I also recognize that, again, there is such a long way to go and that in medicine, much like a lot of, you know, other institutions are still very traditional and are not very quick to accept change.

Dr. Caroline Gérin-Lajoie: Kenneth, what would you like to add to that?

Dr. Kenneth Fung: I also agree that this is only at the very beginning. I think that this long journey towards equity, diversity and inclusion and I think the journey has been and may or may always be an uncomfortable one for a lot of people. I think we have to come through a lot of denial. I think that medicine as a profession, we all know to do no harm.

We all aspire to do good and to care for people. So I think it is jarring to to admit that there is something systemically wrong. I think that contributes to part of the denial. Secondly, I think that modern medicine prides itself on being scientific, and there may be a presumption that if you are scientific, then all these other factors kind of go away. They are like the noise that is kind of in the background that you should be a partialled out and that at the core, scientifically, biologically, we're all the same. I think there are those assumptions as well that may make people downplay it.

So I think that to admit to systemic racism in a medical system would be extremely challenging because the whole system supposedly is there to only do good and to heal people. And it is a noble profession. So I think that that transition would be a tough one. So I think then that even though right now we have a lot of attention being paid to it, I think that it challenges a lot of people in the profession.

Dr. Kenneth Fung: I think a lot of people are sympathetic for sure. But, A, we don't want to think of ourselves as racists, so meaning that we would probably downplay and minimize it. We're going to think, oh, it's just a few bad apples or it only happens to very few people. Those are the exceptional cases.
So I think that that minimization will probably continue to go on. And then the other is challenging our roles, because when we're talking about racism, I think that to do something about it, people would think that well there are activists who would do that.

So I think that for a lot of physicians, they may even be sympathetic, empathetic, but they may not see it as part of their responsibility. They would say I would support it, but since I'm not, activists will leave it to the professionals. And I think that can continue, of course, to contribute to the status quo. The system is has a lot of blind spots, and so, too, to overcome it would take a concerted conscious effort and needs to involve everyone, whether you consider yourself activists or not activists, because we're all part of the system.

Dr. Caroline Gérin-Lajoie: So it sounds like both of you are agreeing that although there seems to be a start in the medical profession, there's still a long way to go. Joseph? A research paper you co-authored examines experiences of racism amongst black physicians and trainees. What did you uncover in that study?

Dr. Joseph Mpalirwa: A research study was really conceived of a combination of a couple of things. The first was a desire to synthesize our stories as black physicians and trainees into a format that was more formalized and less anecdotal.

The second thing was virtually none of the research, specifically looking at experiences of black physicians, existed here in Canada. So basically we conducted a qualitative survey of black physicians and trainees here in Ontario. So our study really highlighted that experiences of racism, specifically of anti-black racism, were indeed occurring in medicine, despite our collective reluctance to admit as much, and that these experiences have a significant impact on the lives of black physicians and trainees.

Specific highlights included the fact that about 70 percent of our survey participants reported having negative experiences as a result of their black race. And these ranged from seemingly innocuous things, micro aggressions, things like constantly being mistaken for floor aids, cleaning staff, nursing or receiving unsolicited comments about their experiences to more overtly racist experiences where, for example, patients would decline to see them because they were black or they would undermine the knowledge or expertise of a black physician until a white colleague basically endorsed them.

The participants reported a lack of general support, a lack of mentorship, less access to opportunities and lack of recognition for the work that they were doing as compared to their non-black peers. There were some positives as well, and these basically highlighted the importance of community, the community that's built amongst black physicians and trainees, as well as other black allied health, and also on the impact that the black physicians were having in advancing the health of of their black patients.

Dr. Caroline Gérin-Lajoie: And Joseph, were you surprised by those findings or were they consistent with either your experience or what you had observed?

Dr. Joseph Mpalirwa: I think the findings are pretty consistent with a lot of the conversations that we were having. I don't think any of it surprised us as black physicians. It was when I was presenting these findings, when I was discussing them amongst my non black peers, that they were like, oh, really, this is happening because a lot of the times when we would explain what was happening, we would be kind of gaslit into, you know, thinking that maybe we were looking at things a little too much or that maybe our experiences were not happening as they as they actually were.

So a lot of the times we didn't we weren't in a safe enough environment where we felt we could even talk about these experiences. But then with the paper, obviously, we were basically bringing our experiences to the masses and they were the ones who were a bit more surprised than we were.

Dr. Caroline Gérin-Lajoie: And maybe linked to the theme of the lack of research in this area. Kenneth, I just wonder what your thoughts are about that gap in in research?

Dr. Kenneth Fung: Yeah, I think absolutely. I think that there needs to be much more research into the experience of racism and to impact the impact of racism as far reaching impacts on life broadly, the social determinants of health. And that means like housing where we live, the kind of occupation, and that applies even to physicians as well in terms of how likely you're going to get a job, how far you're going to go.

So, for example, in the Asian race, there is the so-called bamboo ceiling. What that means is just like the glass ceiling for women, Asians can be seen as, oh, you know, you can succeed. But there is a certain level beyond which there's there's a ceiling that Asians are not seen as, you know, leadership material. There would be the hard working, you know, individuals who are silently working away, for example. So I think that all of this, you know, they have both a psychological dimension as well as as well as a real life consequence. And it can also be even multigenerational.

Dr. Caroline Gérin-Lajoie: Kenneth, you've spoken publicly about racist comments and attacks on the Asian community during the pandemic. Can you explain more and also how this has impacted you?

Dr. Kenneth Fung: Yeah, I think that we all know from the pandemic that an Asian racism is higher than ever before. Of course, there there's a long history of anti-Asian racism in Canada dating back to the founding of the country when the railroad was being built upon the backs of a lot of Chinese people who were brought over to finish their railroad, often in very hazardous and unfair and exploited conditions. I think that chapter of the history may not be well known as far as Chinese being seen as inferior and made ineligible to to vote. And and then there was the Head Tax that were imposed on the Chinese people under legislation and any means to kind of suppress the Chinese people. John A. MacDonald saying many racist remarks about the Chinese population. There's a long history of that.

But certainly since the pandemic, this has been much more, I guess, even acceptable to have for these anti-Asian sentiments to to become manifest. I think we hear that in the political spectrum in terms of how the virus was named or referred to with the influence from our southern friendly neighbors. And so that does, of course, make a lot of racist remarks becoming more surface and apparent with direct attacks. With the Angus Reid poll, for example, showing last year that, you know, half of those who were surveyed who are Chinese had directly been insulted and including like 40 percent were personally threatened and intimidated.

And the CCNC of Toronto had completed voluntary reporting. And over the past year, over 1100 cases of people reporting. Of course, that's a vast even underestimate of people who go to the website and report, including like about one in 10 being physical attacks, one in 10, another one in ten being spat on during the pandemic. Right. So and this is including my own father. And I'm sure my father didn't report anything. He only reported to me and said that a car stopped at a stop sign just to roll down the window and told him to to go back home. So I think all of us have kind of experienced this.

But certainly with the pandemic, this is heightened to a degree that is unbelievable. I think that the reaction has been a very wide mix of reactions. And this is both seen from family as well as friends and colleagues and patients. Some are, of course, minimise it as some are afraid. Like I talked to a patient today and I said, well, how has this racism been bothering you? And she says, oh, no, you know, it doesn't affect me all at all. It doesn't affect me at all, really. OK, well, as we talk further, she says that's because she's now afraid to go out.

She's like an elderly lady. And so, of course, it doesn't affect her, she says, because she's afraid to go out with all these racist attacks. Right. So does it affect her? Of course it does. And there you see that a lot of the emotions are so mixed that there's fear, there's anger, there's outrage, there's powerlessness. And in the Asian culture, there's so much emphasis on harmony, not making noise. That makes it hard for a lot of people to admit to the fact that they experience racism. I mean, research has shown this, which is a lot of Chinese Canadians among the different racial groups has one of the lowest sense of belonging, because it doesn't matter if you're a second or third or fourth or fifth generation Canadians, people might still like, ask where do you come from and where do you really, really come from or where do you really, really, really come from? And of course, this is not to mention people who speak with an accent. And we've seen a lot of this even with the SARS pandemic, but with the COVID, it's just magnified many times over. So it doesn't matter how long you've been in Canada, it never can feel quite like home for a lot of people. Or if they do, it takes just this remark of, you know, where do you come from? Or go back home, in these circumstances, that you feel stunned.

And suddenly it's as if you don't have a home yourself as a, as a Canadian. And I think for Asians, this concept of model, model minority is a powerfully destructive concept. And we call it the myth, the myth of model minority. And it's been around for years that there's the myth that I guess Asians are doing OK. They are not as subjected to the degree of racism that's overt. And look, they get good math scores and it's OK to make fun of Asian people as math nerds or high achievers. But this kind of stereotypes, which I think on the surface of it says, wow, I guess that stereotype is positive. You are stereotype to be smart, to be hardworking. But there are so many problems with it.

Number one, it just doesn't describe certainly everyone. It actually sweeps a lot of the inequities under the rug that you can still see in terms of disparities of every thing you look at from income, to as we talk about job positions, to employment, the rates of employment, to housing, to other social determinants of health. If you look at it, you find that it is not what this myth tells you.

Dr. Caroline Gérin-Lajoie: What do we know about the experience of racism and its impact specifically on physician wellness? Because you both have shared different types of impacts on individuals. But in the area of physician wellness, what do you feel is a potential impact?

Dr. Joseph Mpalirwa: There's an American educator and critical race theorist, William A. Smith, who describes this term racial battle fatigue, basically speaks about various psychophysiological symptoms, things like palpitations, anxiety, depression, elevated blood pressure, symptoms that people of color often experience living in and navigating historically white spaces. He even went so far as to describe, you know, racial battle fatigue as a public health and mental health illness. And I think all this applies to medicine as well, seeing as it's traditionally predominantly white space.

And then added to this is how stressful on baseline, you know, the training in medicine is. You can imagine the significance that this added stressor for black and other underrepresented minority physicians. And you can think about the effects that this may have on their mental and physical well-being.

Dr. Kenneth Fung: I agree so much with what Joseph has shared. And I think for physicians, I think it can definitely add to the stress and increase the risk of burnout, experiencing racism. And racism can occur in so many different settings and so many different contexts.

So, for instance, many visible minority physicians have had the experience of experiencing racism from patients or patients families, as we've heard. And that I think provokes a lot of anger, pain, a sense of kind of betrayal by, you know, you are doing your best to be a healthcare provider, but the patients and their families make racist comments or actions. And there is also this sense of helplessness, like they are your patients or they are your patients families, or even if you share with a colleague, they would say, well, you know, their patients or maybe they are a little delirious or maybe it's the delirium speaking or maybe is the depression or whatever, they're stressed. And I think that is, again, disheartening for a lot of physicians, because I think just like in any profession, you want to have the sense of collective, again, the sense of belonging that you fit in. Right. We are a part of medical culture for the better or for the worse. You want to be one of the guys, one of the girls who hang out in doctor's lounge and and feel just as at ease. But that doesn't always happen.

And for instance, there an experience where someone has run a Chinese and Asian mental health program, for example, who've encountered complaints that in the staff room that some of my program staff spoke in Chinese and someone complained. And it got back to me and I was advised to talk to my staff that if they want to speak Chinese, they should do so in the private office, that perhaps in staff area it should be English only. So this may sound shocking, but, you know, this is what can happen at a systemic level. So and people would say like, well, when I was a, I'm an immigrant, I learned English. So I don't see why people have to speak anything other than English.

So, so, we can see that that it can be highly demoralizing and putting people at a risk of burnout when you are faced with patient encounters that that are racist in nature and then in a system where you feel you are not part of or that you are oppressed in some way because as you know, physician wellness and burnout, it depends a lot on whether you feel that you have some degree of control because there are so many unknowns that we face every day, so many things that we cannot control.

And I would say by nature, we as physicians want to be in control. That's why we are study years and years of medical school. That's because even though we know we save face with uncertainty, we feel better when there's a diagnosis after the 11th tests. We feel better if we have a name for syndromes, even though we're not quite sure what's going on. And so to to be put in a system where you're oppressed and you do not have that control, I think that causes a lot of pain and burnout for for physicians.

And of course, I think in trainees, there's another whole category where, you know, I can even recall instances like that where people remark, make racial remarks and they can even happen from staff. And as a resident, as a student, you feel completely, again, powerless. And we know from surveys that residents experience it, that trainees experience it. But there's hardly a safe space when there is that power dynamic to challenge the system. In fact, the whole reason I got interested in cultural psychiatry is that on one of my earliest young PGY2 rotations, I spoke up about two patients, about their cultural practices and how that may be misconstrued as pathology, as noncooperative. How come they are not cooperating with the nurses? And when I remarked on that, they came back in the form of evaluation that I was a good resident, but I wasn't so much I was kind of colluding with the patient a little bit, just too much.

So that this is an example where when you stand up for these things, sometimes there are consequences. And I think for physicians compounding all of this, as we know in physician wellness, is that we are all trained to be able to take care of other people. And so we feel that we should have the answers. But, you know, if we talk about being hurt from racism or being angry or being depressed or feeling burnt out, how many physicians are willing to admit to themselves, this is really getting to me? And I think that being a physician makes it that much harder to have this additional burden that we feel like we ought to be able to kind of bounce back from anything and brush it off. So I think that we need to be able to acknowledge and the impact of racism. It isn't just your being a. Sort of person or a cry-baby, it isn't because you don't make the cut as a physician when you voice out these incidents and how how badly it hurts you, I think we need to be able to allow people a safe space to be able to share these experiences.

Dr. Caroline Gérin-Lajoie: And so both of you have highlighted that link with racism, discrimination, experiences with heightened stress, with heightened burnout. And maybe in the future, research can establish or examine racism as a risk factor for physician wellness issues. Now, I'd like to switch gears a little bit to start talking about what we can do. Let's switch to action, Joseph, starting with you. In your paper, you explained that only two of the black physicians you interviewed received training on how to deal with negative experiences of racism. So what does that say to you?

Dr. Joseph Mpalirwa: Yeah, I think that what that highlights the biggest thing is that it's a reflection of how little we value or how little we have valued or acknowledged that racism is an issue specifically in medicine.

I think, again, there's been such a fear of talking about the experiences of racism on a wider platform, maybe because people don't really know how to talk about things. And again, it seems like such a big issue, such a systemic issue, that people don't want to take up the task to kind of to tackle the issue. But I think things are starting to change for the better. At my alma mater, U of T, you know, they've introduced some core curriculum teaching on anti-black racism. You know, we're starting to highlight the importance of diversity and inclusion training that pertains to that specific ways in which to address, you know, issues of racism when they arise. So I'm hopeful that things are a bit better and that they are a bit better for the younger trainees as compared to what I had and what perhaps was happening when other older folks were going through their training.

Dr. Caroline Gérin-Lajoie: Kenneth, what else would you like to add in terms of things that you'd like to see put in place to help address the mental health impacts of racism in medicine?

Dr. Kenneth Fung: A lot of people, of course, see racism is as evil and as bad, and hence being a racist must be evil and bad, and hence it's incompatible that any doctors or the system is evil and bad. So I think that, in other words, I think we need certainly to make a safe, safe space for us to talk about our racist experience. We also need to make it a safe space for us to admit to that there is racism in the system. Yes, there needs to absolutely. There needs to be accountability. There needs to be change. Yet I think that we need to consider how to make it a safe space so that if people draw attention to the systemic issue in medicine, we are not saying, OK, now we brand you forever and you to seventh or eighth level of hell or something like that.

So we need to be able to make it safe for us to do that, because as we know, if we want to decrease medical errors, having that non blaming culture as we do with QI projects identify problems. We need to have that non blaming culture. If if we're not really going to take a hard look at who we are in, you know, positions of power in the hospital structure system, who is making the decision and hospital policies that we don't really take a critical look at who's hired, who gets into the medical system, all of this, who becomes teachers and what kind of research is being done and the whole industry of medicine.

This field of medicine in a systemic way, we're not going to be able to address it. And then from the EDI, the D is very important, the diversity. We say diversity is strength and that is nice as the Canadian dream. I think that's better than the American dream. We can have the Canadian dream as diversity as the true source of our power isn't that a beautiful thing? And so we need to enact that dream and turn it into reality. So I think that does mean policies too. We're going to need report cards. We're going to need parameters. We're going to need policies that improves equity. So if there are decisions that are made that makes equity worse, we need to look into that so that we enact it. And if there are racist incidents to have this supportive environment for this to be reported, and I think that needs to be investments and structural changes then, because like anything, it's not just talk and we all feel good. We need to translate it into some form of action, as we say.

Dr. Caroline Gérin-Lajoie: And as my final question, and I believe this is a very important one, if there is a trainee or a practicing physician listening to this podcast who's presently experiencing micro aggressions, racism, discrimination or who's being uttered, what message would you give them? And we'll start with you, Joseph.

Dr. Joseph Mpalirwa: Yeah, I think my main message would be that, you know, you're not alone. Find your community, your community, whether it's people that look like you or whether it's people who have similar shared experience, find your community and lean on that community. And also don't be afraid to to speak out when these things are happening to you, because we're not going to know how prevalent an issue is until we are all speaking out about it. Medicine science is very pragmatic. And if we have the research to back up what we're saying, then that's going to make a stronger argument for change. So just speak out and also find those communities of support because they will be what will get you through those tough situations.

Dr. Caroline Gérin-Lajoie: And Kenneth?

Dr. Kenneth Fung: I think that message, number one would be take care of yourself first and do whatever you need for you to feel OK and safe because people's sense of safety is being threatened. So and to cope with things in the way that they they like just like we know in psychiatry sometimes, you know, when you hear this, some allies or some mentors may feel so outraged like you got to do something and the person may or may not be ready and the person might say, what I need is an ice cream. That's that's what I need now. And so so I would say, OK, let's stop listening to the podcasts on anti-racism and let's have a cup of ice cream and then we'll talk later, OK? So sometimes what they need is like, ice cream. I'm sorry that, you know, we are in CMA, physician wellness, frozen yogurt, diet, frozen yogurt. OK, so so take care of yourself first. So that's number one. We have to acknowledge the seriousness of this and it means different things to different people and they need to deal with it in their own way. At the same time, we want to make sure that we have an open, welcoming space, that this is an issue that I'm willing to support you through so that when you feel ready, we want we can talk more about it because it does help.

Dr. Kenneth Fung: I think this kind of encouragement is helpful. I think I want to underline just this message that you are not alone. Reach out to families, friends, communities, because you can get support and of course, enlarging the circle of trusted colleagues and allies. And finally, it is to empower the person to take steps. And I think we can all take different kinds of steps. Not every one of us feel like we can, you know, do a public speaking or, you know, but we can all help in different ways. And a lot of the times we know it is a systemic issue and sometimes means collective action. It means that sometimes signing up with others who start a petition letter, sometimes it means joining with other causes of social justice. So we all find you can find different ways to be part of the solution. And when people feel that there's something that they can do right and they feel more empowered.

Dr. Caroline Gérin-Lajoie: Thank you both for your time and your thoughtful perspective, this has been an extremely important conversation and I hope that it will help to amplify your voices. And also, Kenneth, I hope that your Canadian dream comes true where diversity is the source of power in this country. Dr. Kenneth Fung is a staff psychiatrist and clinical director of the Asian Initiative in Mental Health at Toronto Western Hospital. He is also an associate professor with Equity, Gender and Populations Division in the Department of Psychiatry at the University of Toronto. Dr. Joseph Mpalirwa is a family physician and inpatient physician at Toronto's Casey's House and a member of the Black Physicians of Ontario. He recently co-authored a study published in Academic Medicine about Black physicians experiences of racism and discrimination in Ontario.

Sound Mind: Racism in medicine

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Related resources

Canada's Healthy Workplace Month

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Being Indigenous in med school

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Are you in distress? Get help now.