Minority Residents Face Double Burden

“Am I being oversensitive?” Tracee Burroughs, M.D., a resident at the University of Maryland in Baltimore, asked herself. Burroughs and other psychiatry residents raised the question at APA's 2007 annual meeting in San Diego in a workshop tackling the prejudices they have encountered in the course of their training. The workshop was presented by the APA/SAMHSA Minority Fellows.

For Burroughs, the question arose—and not for the first time—when as a first-year resident, she asked a nurse to check a patient's blood sugar and the nurse just walked away. Why? she thought. Did the nurse mistake her for a nursing student or some other nonphysician? Did she ignore Burroughs because she was young or a woman or black? When such events happen once, she can shrug them off, she said. “But when it happens day in and day out, it's an 'ism.'”

These residents talked about the various forms of prejudice they encounter in their work, from patients, fellow doctors, or staff. They've experienced or observed bias based on race, class, gender, age, physical ability, and sexual orientation—the “isms.”

“The experiences with the 'isms' the residents describe are very familiar to me,” said Annelle Primm, M.D., M.P.H., director of APA's Office of Minority/National Affairs, in an interview. “'Isms,' both intentional and unintentional, are destructive and painful. They can shake one's confidence, drain time and energy, and distract trainees from their goals.”

It is the routine aspects of these events that erode the person from within, said Burroughs. “You start to doubt yourself and your role as a physician, and that affects patient care.”

Chester Pierce, M.D., professor emeritus of psychiatry and education at Harvard University, has called these small wounds“ micro-aggressions,” subtle blows delivered incessantly. They result when members of privileged groups—however they might be defined in any one instance—exert their power over the less privileged.

Physicians who are members of minority groups face a double burden. By virtue of their education and position in society they are members of a privileged group, but they are still perceived first as“ minorities” and may encounter discrimination on personal, institutional, or sociocultural levels that devalues years of study and training.

Or as New York physician Mana Lumumba-Kasongo, M.D., wrote in the April 3, 2006, Newsweek, “My black skin makes my white coat vanish.”

A second resident, Alphonso Nichols III, M.D., of the University of Louisville recalled his experiences with a white male patient who refused treatment by Nichols, an African American. Nichols had to work out his anger and frustration with the patient in discussions with his supervisors. A white mentor encouraged him to “hang in there” in the face of the patient's overt racism, but a black supervisor eventually persuaded her senior colleagues that conflict represented a barrier to treatment. Nichols ultimately relinquished care of the patient to a white colleague.

Sometimes prejudice can work in the other direction, to the detriment of the patient, when “positive” prejudices guide behavior.

Burroughs recalled the case of a 45-year-old African-American investment banker who presented at her hospital with an altered mental status. The patient mentioned that he had taken a lot of acetaminophen to relieve pain after a heavy gym workout. Since that seemed to account for his symptoms, he was discharged. Later, the physicians on duty realized that they had failed to screen the man for possible suicidality. They assumed the man's upper-middle-class socioeconomic status was a protective factor and he wasn't examined closely.

Burroughs took away an important lesson from the incident: “Not only the poor fail to get the standard of care.”

In another incident, Burroughs overheard other medical students talking about their classmates. They assumed that all the black students had gained their positions through affirmative action and thus hadn't had to work as hard as other students. Hearing those assumptions was painful to Burroughs, a Phi Beta Kappa graduate of Howard University.

A third speaker, Eugene Lee, M.D., now a resident at Cedars Sinai Hospital in Los Angeles, related his earlier experience as a patient at a community clinic, which discriminated against him in terms of the care it offered after learning that Lee was gay.

Responding to the residents' stories, Marshall Forstein, M.D., an associate professor of psychiatry and director of psychiatry residency training at Harvard Medical School, said he understood how hard it is for residents to cope with such experiences. “It is difficult to find the voice to discuss or confront these micro-aggressions,” said Forstein, who is gay.“ How long should you be asked to 'hang in there' in the name of training?”

There is little research in this area, he said in a later interview with Psychiatric News. How often trainees encounter these micro-aggressions during their postgraduate years varies by region and in response to the tone set by each department.

The panel at the annual meeting pointed out the common aspects of such discrimination, Forstein told Psychiatric News.

“The residents all feel devalued, undermined by prejudiced patients, and weighed down by an extra burden,” he said. “We need to understand the impact of discrimination and stigma on them and their work but not lower our standards. It is important not to let it get them depressed.”

How residents respond to each event depends on both their own character and the backing they get from supervisors. Faculty members who have weathered similar experiences can offer insight to residents, validate those experiences, and serve as role models in dealing with prejudice. Faculty members who have not experienced such stigma in their own lives may not understand what these residents go through, so residency directors should incorporate discussion of discrimination into all aspects of training and faculty development, he said.

“Since the 'isms' are ubiquitous, we need to find ways to teach residents how to cope in order to help them achieve and maintain a sense of well-being,” said APA's Primm.

Residents themselves can move beyond prejudice and discrimination by finding connections outside the “skin-deep stuff” to build a sense of community and reconcile the privileged and oppressed aspects of one's life, said moderator Karen Ron-Li Liaw, M.D., a fourth-year resident at Massachusetts General Hospital. ▪