Race and residency training in the post-Charlottesville era

Naturally, I was on edge when I heard about the alt-right rally scheduled in our town last summer. I was on call for both general surgery and trauma during the weekend of the August 12, 2017, Unite the Right rally. Every available member of our surgical residency program was present, whether on call or not, and assembled into trauma teams. When we received notice that violence was occurring in downtown Charlottesville, VA, I joined an entire army of hospital staff of all backgrounds as we rallied together, braced ourselves for the response, and did what we do best—care for the sick and injured. There were no voices of hate or frustration from the medical staff that day, only effective communication to respond and coordinate care for those in need. It was one of the most inspiring moments of my life.

Earlier experiences with race

Charlottesville’s racial homogeneity is no different than that of many U.S. towns and cities, and its whiteness does not intimidate me. This was true when I began my surgical training several years ago, long before white supremacists descended upon our town. I am no stranger to being the only black person in a room.

I grew up in a rural community in Kentucky that was more than 90 percent white. Whether being called a “nigger” for accidentally bumping into a fellow classmate in the hallway or losing the opportunity to be one of the first black valedictorians at my high school due to a last-minute policy change, throughout my life I have been reminded covertly and overtly that I am black.

As a high school student volunteering at my local community hospital, I was sent to comfort newborns when members of the Ku Klux Klan (KKK) from a neighboring county would come have their babies delivered at our hospital. I never feared these individuals who proudly displayed their shaved heads and swastika tattoos, but they served as a visible reminder of the overt racism and discrimination that has always been a part of American history.

The same stigma that I confronted as a child in rural Kentucky has followed me North and South, through the halls of elite academic institutions, and into the operating rooms (ORs) and clinics where I now train as surgical resident. I was naïve to think that becoming a physician would spare me from the stigma associated with my complexion. My academic achievements did not matter to the nurse who ordered me to retrieve the catheter and blanket, thinking that I was an OR tech, yet soon found out that I was the resident physician taking care of our shared patient. I experience a brief moment of tension, uncertainty, and doubt that seems to pervade the room when a patient is surprised that his or her physician is young, female, and black. In addition to the normal stresses and challenges of residency, my colleagues from different gender, ethnic, religious and other underrepresented minority groups face hurtful acts of ignorance from both colleagues and patients. These little instances build the perception of intolerance, no matter how strong the message of diversity and inclusion is broadcast for the public’s consumption.

Starting a discussion

Studies that examine challenges facing minority trainees rarely have been explored; however, several qualitative studies have started the difficult work of describing these experiences.1,2 Chief among issues identified by black trainees include the simple fact that being a black trainee in the U.S. makes you highly visible. By nature, trainees of color stand out, which can make them feel more vulnerable and prone to criticism.1 In the months following the rally and counter-protest, I have been touched by the unity and support from the Charlottesville community and my colleagues. Fellow trainees have come forward to share instances where they have been openly discriminated against either in our community or within the hospital. Instances where some patients have refused care from one of my non-white colleagues have come to light. I have heard the groans of staff members when a non-English speaking patient presents for evaluation in clinic. These examples demonstrate that this problem has been longstanding in our town, and it did not start the weekend of the rally.

Though I had a solidly middle-class upbringing and have experienced many forms of privilege in my life, the America that I know and the Charlottesville that I know have not always been comfortable with minorities existing in this predominantly white space. Now it is my job to stand up and tell people why it matters that trainees of color are here and why it is important that we stay. We have not and may never be a post-racial or color-blind society. We can, however, be present in the moment. We can recognize suffering as a universal phenomenon. We can encourage discourse where before there existed only silence. I want my fellow trainees, particularly junior residents and medical students, to know that I am here for them and that many in their community both want and need them to be present, sharing their knowledge and their talents. This is a duty I am happy to uphold.

Going forward, we all must recognize this problem will not fade away. Leaders of the alt-right movement have already vowed to return to Charlottesville, and stories of rallies elsewhere have become widespread. Although I was not shocked that a group of white supremacists, neo-Nazis, and KKK members were planning to rally in our town, I was surprised at how some individuals have reacted. “How could this happen here?” many have asked. I cannot say I wonder the same thing. There is a veil of discrimination and racial divide that was present in this town long before I arrived. I appeal to all of my friends and colleagues at this critical time: we cannot afford for you to treat this incident as the fad or hashtag of the moment. We cannot go back to our respective corners and proceed with business as usual. You need to stand up to white supremacy in all its forms, whether it appears in the form of Nazi imagery or in colloquial conversation through a joke or stereotype.

Your protest must be greater and more forceful than a candlelight vigil; words and actions that oppose this hatred must become a part of your daily life. When a friend or colleague comes to you after a patient or co-worker has said something denigrating and insulting to them, take time to listen and understand rather than dismiss it as being all in their head. If the events from the Unite the Right rally reveal anything, it is that racism is real, and it is present here. You witnessed it on your doorstep.

A path forward

Very little has been written regarding how to best confront challenges faced by trainees of color, and almost zero data are available regarding how or whether this experience differs for surgical trainees versus trainees in nonsurgical training programs. Butler and colleagues demonstrated a profound discrepancy in the number of underrepresented minorities among U.S. surgical residents, with only 4.7 percent black residents compared with 64.4 percent white residents. Furthermore, blacks represent only 2.9 percent of U.S. academic surgeons.3,4

The limited body of research that does exist on this topic suggests a few particular actions that might enhance the training environment for black residents. These recommendations include the following:

  • Acknowledgement by majority faculty and residency leadership of how residents’ race may influence their experience as surgical trainees. This recognition may help combat the sense of vulnerability associated with being an underrepresented minority in surgical training.1,5
  • Formal and structured programs for mentoring and career development for all residents, which may ensure that opportunities that encourage pursuit of research, resident leadership activities, and academic development are offered in a more equitable fashion to all trainees. Mentorship and research during training have been shown to influence the pursuit of an academic career, an important finding given the continued underrepresentation of physicians of color in academic medicine.3,4
  • Actively shaping a programmatic and institutional environment that encourages discussion and recognition of “racial fatigue,” which may include creating opportunities for trainees of color to have planned social support in both formal and informal settings. Specific institutional mechanisms to respond to instances of racism and bigotry experienced by trainees should be well-defined and a faculty champion designated.2
  • Coordination of an institutional action plan to advocate for faculty, staff, and trainees facing discrimination from patients who exhibit discriminatory behavior. This protocol should include both a pathway for reporting this inappropriate behavior and designation of a core group of individuals who are available to respond to these issues on behalf of the institution.

Implementing these steps is not going to be easy. Just as the caretakers of Monticello have sought to unify the complicated pieces of Thomas Jefferson’s history intertwined with the tales of slaves who lived and suffered under the yolk of slavery on top of the hill that overlooks Charlottesville, we must rebuild our perceptions of race and how it impacts surgical training. The previously held assumption that our city and others like it is a safe zone for students and learners of all backgrounds has been effectively shattered. As we rebuild from the tragedy resulting from the rally, it is important to do so in unity.

Training programs with predominantly white, male leadership must create an environment where trainees from all backgrounds can thrive and learn. Other authors have written about the importance of black trainees working in an environment where they can receive encouragement and affirmation from all faculty members.1

Creating a better workspace for minority trainees, therefore, means recommitment to and redoubling of efforts aimed at recruiting both black faculty and trainees. It means formulating a targeted and specific plan for increasing diversity in surgical training programs, and this is a step that has already been taken at the University of Virginia and in the department of surgery, specifically.

After departmental debriefings in the wake of this tragedy, I know now more than ever that I am not the only one to experience racism, sexism, and bigotry at work. It happens often—more than many people are comfortable admitting. Conversations surrounding race and ethnicity are never going to be easy, but if we do not use this opportunity to try, we may never again get the chance. Standing firm and speaking up is the only way we can move forward.

Acknowledgements

The author would like to acknowledge Charles Friel, MD, FACS, and Victor Zaydfudim, MD, MPH, FACS, for their generous edits, contributions, and support in the authoring of this manuscript.


References

  1. Liebschutz JM, Darko GO, Finley EP, Cawse JM, Bharel M, Orlander JD. In the minority: Black physicians in residency and their experiences. J Natl Med Assoc. 2006;98(9):1441-1448.
  2. Nunez-Smith M, Curry LA, Bigby J, Berg D, Krumholz HM, Bradley EH. Impact of race on the professional lives of physicians of African descent. Ann Intern Med. 2007;146(1):45-51.
  3. Butler PD, Longaker MT, Britt LD. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg. 2008;248(5):704-711.
  4. Julien JS, Lang R, Brown TN, et al. Minority underrepresentation in academia: Factors impacting careers of surgery residents. J Racial Ethn Health Disparities. 2014;1(4):238-246.
  5. Wong RL, Sullivan MC, Yeo HL, Roman SA, Bell RH, Jr., Sosa JA. Race and surgical residency: Results from a national survey of 4339 U.S. general surgery residents. Ann Surg. 2013;257(4):782-787.

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