Facing Invisible Giants

by Dr. Myrna Alexander Nickens, Vice Chair for Diversity and Inclusion, Department of Medicine

This July, the interns and new fellows in the field of medicine begin an extraordinary journey, one where they will need to adjust to their roles as primary care providers in a very uncertain environment.  As the house staff class of 2020-21, they may have anxiety about caring for patients diagnosed with Covid-19, understanding that there is not yet a cure for this highly infectious virus. These interns and fellows may be challenged to find balance at a time when uncertainty exists not only about Covid-19, but also about the social justice issue of racism that has led to mass protests, riots, and upheavals worldwide. Our world has become smaller and smaller.  Within six months, Covid-19 alone has taken the lives of half a million people, 25% of them in the USA. 

Who could have foreseen that just a month ago the life of a black man, George Floyd, would have been taken by a white policeman who pinned Floyd’s neck under his knee? As the world repeatedly watched the video of this unmerciful death, a surge of protests against racial injustice around the world was provoked and continues. “When it rains, it pours” is an old saying that might be relevant to the world situation today. We have had natural disasters including floods, tornadoes and more recently a sandstorm to invade the United States of America.  Our routine has been interrupted by massive job loss and social distancing. Physicians have taken an oath to treat human beings regardless of race, ethnicity, social background, sexual orientation, insured or not, citizens or not, obese or skinny, etc.  Many pursue medical careers for the stellar reasons like compassion, finding the cure for diseases, improving the health of patients and other good motives. Sometimes, these good intentions become lost somewhere between medical school and years of practice.

As I look back several decades ago when I was a 4^th year student, I couldn’t wait to get my intern pager.  Now, I can’t find my pager.  It is pushed away in a drawer somewhere, now that the cellphone allows me to use one step to communicate versus making 2-3 calls.  The pager served as a symbolic baton passed with a certain amount of pride, responsibility, and anxiety about the reality of being a full-fledged physician. In the pursuit of my profession, I never thought about the possibility of being exposed to any disease that could cause immediate illness or even death. The Sars-2-Coronavirus is today’s invisible giant that can do just that. 

The risk of contracting serious illness in treating a contagious coughing patient with tuberculosis or an inadvertent needle stick from a patient with hepatitis or HIV has always been a possibility. However, the stakes are a bit higher these days — both in the medical environment and in the communities where we live.

Racism and sexism lurked the hallways as I completed residency training, but these issues were not a daily concern for me. The Hippocratic Oath cited just months before entering my internship preoccupied my mind more than anything else. I was focused on providing the best patient care without harm, and nothing else was allowed to take priority.

One of the secrets to successful transition from medical school to residency is a team approach to patient care. Being able to call on an upper level resident was always comforting in the middle of the night for me. Those late-night emergencies created lifelong relationships and stories with my colleagues. We still laugh about some of these. I recall a time as an intern when a diabetic woman screamed in agony to the nurses about her pain. I rushed to the bedside of the elderly lady in distress.  My exam revealed lower abdominal tenderness with rebound, surely secondary to an acute abdomen.  I faced the dilemma of whether to call for an immediate surgical consultation or to call my upper level resident. I called my upper level resident and was glad that I did. A very confident African American woman appeared at 2am. Her exam, of course, did not reveal an acute abdomen due to appendicitis, but rather urinary retention cured by inserting a foley catheter.  We are still laughing about that night.

This experience from the pages of my internship illustrates the importance of not “going it alone.” The upper level residents, fellows, and attending staff are there to lead the team to ensure proper diagnosis, patient safety and compassion. Be sure to take advantage of this.

Because physicians do not live in a vacuum, we cannot afford to ignore the implications of racism and biases in our communities. The invisible giant of racism — like the coronavirus — prowls around blatantly as well as unnoticed. Racism is often difficult to talk about honestly, even though it has been around for centuries. Both explicit and implicit biases can be expressed by residents, fellows and attending physicians. Teams with such issues generally are less productive.

Patients also weigh in on this issue. “I want a male doctor, a white doctor, a black doctor, or a southern speaking doctor treating me” are typical phrases we hear. A good team can handle an array of issues effectively, building strong bonds at the same time. The attending physician and upper level house officers serve as exemplars for the intern.  Implicit and explicit biases potentially may be more destructive than COVID.  Within several months or years, the viral pandemic might be controlled.  However, racial biases are a contagion that may not be overcome anytime soon. Our responsibility is to know how to face racism in a way that ensures excellent patient care. We do this foremost by putting our own negative biases aside.  Physicians must always have care and compassion at the top of our agenda as we treat every patient.

Care and compassion are qualities we all need during these stressful times in America. Americans must pull together to overcome both the COVID pandemic and racial discrimination. Staying safe with a mask, proper hand washing, and social distancing will decrease the viral spread.  Changing negative biases takes more effort and involves more people invested in the proposition of better days ahead.  Doing so will bring wholeness in America and perhaps inspire it globally.