Richard Choi, DO
Please note this opinion piece reflects the views of the author and does not necessarily reflect the position of ChristianaCare.
The recent wave of increased social and racial injustice awareness as well as the significant increase in anti-Asian hate crimes1 have had me reflecting on my life-long cultural and racial experiences.
As a Chinese-Korean American child growing up in Spain in the 80s and 90s, I unfortunately became accustomed to experiencing racist behaviors and slurs such as people holding their eyes in a slanted-eye gesture while yelling ‘Ching Chong.’ In order to blend in, I “white-washed” myself: I refused to speak or cultivate my parents’ native languages or learn about their traditions, customs, or culture and I dressed and spoke in a manner that helped me feel a sense of belonging.
Despite my actions to fit in and my Spanish sense of self-identity, I was constantly and painfully reminded that your external features are immutable, no matter what your cultural upbringing or sense of belonging may be. Recurrent micro-aggressions made me feel like an outsider and I never achieved a sense of belonging. And because belongingness is a basic human emotional need, I know that part of my character and personality was undoubtedly affected by my diminished sense of belonging.
As a child, my parents took me to New York City on multiple occasions where I experienced an incredibly diverse and multicultural mecca. I assumed that the entire United States would be equally as diverse and eagerly left Spain for Philadelphia at the age of 18. I yearned for belonging, still ignorant of how much of my own heritage I had already abandoned to try to fit in.
The cultural diversity I encountered after moving to the US was what I had always imagined. I made friends from all over the world, sampled ethnic cuisines that I had never been exposed to before, learned about many countries and their cultures, and felt like I had found a place to call home. And yet the protests in support of the Black Lives Matter movement after the death of George Floyd on May 25, 2020, as well as the 3,795 incidents of Asian-hate crimes reported by the "Stop AAPI Hate" Foundation2 between March 19, 2020 and February 28, 2021, were a wake-up call that social injustice and systemic racism remain colossal issues in the United States, and that minority groups continue to contend with these issues daily. It began to become painfully apparent to me that the discomfort and injustice that so many have experienced and continue to experience because of systemic racism and inequity was not that dissimilar—yet amplified by several orders of magnitude—to the discomfort that I had experienced growing up.
Because our sense of justice is deeply engrained into our sense of righteousness and morality, strong emotions frequently accompany any feeling of being treated unjustly. This feeling is not unique to humans and is something we share with other animals. Scientists who study animal behavior have shown that rejection of unjust treatment is seen across several species, such as capuchin monkeys (link here3 but you can also watch the experiment here4), dogs, birds and chimpanzees. Because of the injustice and wrongdoing I felt, I vowed to learn more about systemic racism in this country and on its effects on the population and its health.
I educated myself on the Tulsa massacre of 1921, on redlining, on Jim Crow laws, and on “the talk” that parents of all African American children have with their children as they grow up. The fact that I was only learning about these things in detail now—and that some of you may not have heard of them at all (if you haven’t, I urge you to look them up; you can start here5, here6 and here7)—highlights how engrained our collective biases and willful ignorance are.
After the Atlanta-area spa shootings, I also developed a better understanding of how the systemic exclusion of and racism towards minorities in this country also affects those of Asian descent. I learned about the Chinese Exclusion Act of 1882, the Asiatic Barred Zone act of 1917, and read more about the World War II-era internment camps for Japanese-Americans, followed by redlining laws against Japanese residents through covenants written into real estate deeds (start to read more here8).
I was beginning to question the justification and justice of my decision to abandon my heritage for the sake of feeling accepted by a system that demonstrated ongoing systemic racism and resistance to change. I felt morally compelled to develop an ethical response and reaction towards the present social and racial justice movements–not only as a healthcare provider within medicine, but also as a civilian outside of medicine and as a parent to the next generation. But I first wanted to define the moral goals of these movements and determine if such a response was justified.
The principle of justice that “equals should be treated equally and unequals unequally” goes back to Aristotle. In the context of race, justice is interpreted to mean that people of all races should be treated fairly, with equitable opportunities and outcomes for all. While this may seem self-evident to us now, this view represents a modern reinterpretation of the classic Aristotelian principle. Take for example that even Abraham Lincoln said to Stephen Douglas in 18589 that among white and Black people “there must be the position of superior and inferior, and I, as much as any other man, am in favor of the superior position being assigned to the white man.”
It was upon the completion of the Human Genome Project in 2003 that we came upon the realization that race is a cultural and not a biological construct. All humans share 99.9% of their DNA, meaning that there is in fact only one race—the human race (more here10 and here11). As such, the modern interpretation of racial justice is in fact biologically and scientifically sustained and justified.
Medicine, I reaffirmed in my research, is also far from immune from systemic racial injustices. Well-known examples of racism in medicine we all learned about include the Tuskegee syphilis study of the 1930s or the story of Henrietta Lacks, whose cancer cells became the first immortalized human cell line, and which were taken from her without her consent or knowledge. But I found that other examples abound: African American pregnancy-related deaths in our country are twice that of white women12; minority populations are more likely to be uninsured13; and Black Americans have shorter life expectancies 14. While I had seen these figures before, I was only now truly understanding how these differences were the results of systemic racism. The COVID-19 pandemic uncomfortably highlighted to me how minority populations are more likely to get COVID-19, be hospitalized with COVID-19 and die from COVID-19 infections15 because of a myriad of reasons16, including said systemic racial injustice and inequality.
I found that a recent survey conducted by KFF and ESPN’s “The Undefeated” showed how Black Americans have significant distrust towards the healthcare system 17. This distrust is driven in part by recurrent micro-aggressions, condescension, and neglect (please listen to this podcast18 if you have more time), but is also driven by Black and ethnic minorities’ lower quality of health services compared to white Americans, something that is supported by a large body of published data. Within this body of literature I found that Black Americans receive lower quality treatments and have worse outcomes than white Americans (examples here19, here20, here21 here22 and here23); that they are undertreated for pain (examples here24 and here25); and that they experience increased mortality26, with an estimated 74,402 excess deaths per year, on average, between 2016 and 2018 compared to white Americans.
I also discovered that racism in healthcare is not limited to those with poor healthcare literacy or socioeconomic status either. For instance, before Susan Moore (an African American physician) passed away from COVID-19 complications, she reported that she was receiving racist treatment27; Serena Williams was diagnosed with multiple pulmonary emboli after the birth of her child, yet her initial complaints of pain were ignored28.
If justice is such an innate part of our morality, I did not understand how these issues of inequality, both in medicine and outside of it, had gone unaddressed for so long. I wondered what the correct path forward to address these issues was and how to achieve racial justice both within medicine and our national culture.
While these are incredibly complex scenarios to solve, I was glad to see that the medical community has started to address these issues by effecting change. First, the American Medical Association29 and the Centers for Disease Control and Prevention30 have declared racism a public health threat. Within medical education, many medical schools have moved to pass/fail for their courses, as has the USMLE step 1 exam. This is a concerted effort to increase diversity and representation in medicine by reducing the existing cultural and racial biases in coursework and standardized tests (read more here31). Studies (examples here32 and here33) have shown that increased representation within the healthcare industry can help with trust and communication issues and may even help to improve the health outcomes of these patient populations.
I was also happy to see that the Neurocritical Care society has also committed to becoming anti-racist and approved the creation of a new committee—the Inclusion in Neurocritical Care committee (INCC)—in September 2020. The purpose of this committee is to embrace diversity, increase transparency and ensure that opportunities are equal for all (read more here34). I encourage you to participate in the activities that will be hosted by INCC, such as its affinity groups or book clubs.
Within medicine, it is our ethical responsibility and our duty to our patients to pursue racial justice and equity, both from within and outside of medicine. This is because it is only by doing so that we will be able to improve the overall health and outcomes of our African American and other minority patients.
As healthcare professionals, we must work to identify our own internal biases and observe how they affect our practice. Implicit biases contribute to racial healthcare inequality and inequity (see examples here35 and here36) and are present in all of us. These biases are the result of cultural conditioning and can sometimes even be contrary to our personal values. Consider taking an implicit bias test37 if you haven’t done so already. Acknowledging this bias can then help us reclaim our relationships with patients from minority populations and broaden our perspective. I have noticed that I, too, have biases and am working hard to reduce them. In working to reduce my bias, I have discovered that my biases extend beyond race and this introspective exercise is helping me to become a better-rounded provider.
We must approach patient encounters with compassion, openness, and empathy. Restart these relationships with the assumption that we must work to gain our patients’ trust and understand that they may have had hardships, including negative experiences with health systems and providers, of which we are not aware. Practicing empathy is both essential to understanding the injustices that some of our patients have experienced and also to start the therapeutic process of healing from those injustices. This is particularly true for those of us who may not have had to face discrimination in the past.
We must then rewrite our own narrative about how the world works and correct false assumptions. Perhaps a “non-compliant” patient has had poor access to healthcare due to lack of insurance or has felt unfairly treated in the past, leading to mistrust of healthcare. Or consider that a patient’s family member who is angry may mistrust healthcare and does not have the healthcare literacy to navigate a system that they see as being stacked against their loved one. In these instances, before jumping to conclusions or arguing, we must first listen. Listen with open ears, hearts and with humility. You can begin conversations by opening with phrases such as “I understand if you have little faith in me or what I am about to tell you and I am sorry if you have ever experienced racism-related health problems, but I promise you that I am here to be an advocate for you/your loved one, and I will work hard to gain your trust.” Once rapport is established, we can build trust and can then advance our relationship with patients by helping them identify ways to remove the obstacles that stand in the way of their health equity. I vow to continue to always advocate for my patients and have already started to refocus my encounters with reawakened love, transparency, and empathy and have since made deeper and more meaningful connections with my patients and their loved ones.
As healthcare professionals, we must commit to being anti-racist. We must call out racist acts and call in38 micro-aggressions, even if they are coming from a colleague or superior. Micro-aggressions are brief verbal or behavioral indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative insults. Examples include statements made to patients such as: “where are you from?” or “your English is very good.” An approach to dealing with micro-aggressions includes using the mnemonic IPIP (adapted from this powerpoint39):
I – Inquire – ask the speaker to elaborate on what they mean, e.g., What did you mean when you said x?
P – Paraphrase – restate and reframe, e.g., You’re saying…, What would happen if…?
I – “I” statements – communicate the impact of the situation while avoiding blame, e.g., I felt… when you said…
P – Preference statement – communicate your preferences rather than stating them as a demand, e.g., It would be helpful to me if you… or I do not think that was funny, and I would appreciate it if you would stop.
We must also expect that we will conduct micro-aggressions unknowingly, and when we do, we must acknowledge them and apologize. I know that I have committed these myself, and have already apologized to my team for them. I have asked them to let me know if I continue this practice and have embraced a culture of openness and acceptance.
As healthcare professionals there is even more we must do. We can use our status to positively influence our peers and family members, including calling out—and helping to resolve—problematic conversations that happen socially, including on social media. We must demand that our hospital leadership commits to creating an anti-racist environment and diversifies its executive board, adding a Chief Equity Officer position. We must push for our hospitals to diversify their workforce so that they reflect the diversity of the patients we serve. We must join the community in demanding improved access to healthcare for all, improved representation in medical research trials, and we must apply justice to those who do not now receive it under our care by taking institutional action (example of how this can be achieved here40).
I have started a presence on social media—to explore these issues and others—via Twitter (follow me @rkchoi) and I am fortunate that I work for a hospital that has committed to becoming anti-racist and has appointed a Chief Health Equity Officer. I am excited to become involved in the inclusion activities that the hospital is developing and I also plan to investigate whether our stroke outcomes are different for minority groups. I will attempt to correct this issue if I find that there is a difference through institutional action.
Outside of medicine, as civilians, we have an ethical duty to dismantle systemic and structural racism in order to improve our patients’ health and outcomes. These duties start by encouraging and celebrating diversity and acceptance; learning about different cultures; and speaking up whenever we witness an act of racism. Take a free bystander intervention training course such as the ones offered for free at ihollaback.org41, which can teach you how to de-escalate a situation while remaining non-confrontational and staying safe. Get involved in local politics and support leaders who share these goals. Consider donating to organizations focused on fighting racism such as the NAACP (link here42), Black Lives Matter (link here43) or Asian Americans Advancing Justice (link here44).
At our household, we have started to learn about different cultures by celebrating diverse holidays from cultures from all over the world and we intend for these new holidays to become a part of our traditions. My wife and I plan to visit as much of the world with our children as we can. As Mark Twain said, “Travel is fatal to prejudice, bigotry and narrow-mindedness.” I have taken a bystander intervention course and found it illuminating and instructive. I plan to use these newly gained skills if I ever witness unfair treatment or harassment.
As parents, it is imperative that we help our children learn about racism and learn to become anti-racist. By influencing the next generation, we can create a more just and tolerant society. This work starts by educating our children to become more culturally aware and inclusive. Start by buying books, watching movies, and consuming media with your children that contain racially and ethnically diverse characters and stories, and which include children in non-stereotypical roles. Read more about the history of people and cultures with which you are unfamiliar. Have informed conversations about race with your kids, because in not doing so, we risk intensifying stereotypes. It is only by exploring their thoughts that we can allow them to develop a healthy curiosity and knowledge of other cultures. My wife and I have started by purchasing and consuming such media and I have also started having conversations about race with my five-year-old. I am truly in awe at how rapidly and keenly her sense of justice is developing.
It took a seventeen-year-old girl to witness, record and then share a video depicting Mr. Floyd’s death for the world to embrace the racial justice movement. And it is thanks to this movement that I experienced a racial awakening. This awakening has then led me to unearth how systemic racial injustices and my own perpetuation of these engrained systems affect the health outcomes of my patients and I now find it impossible to remain silent.
I encourage you to use the present time to reflect on whether you believe that systemic racial inequality exists and whether it affects the outcomes of your patients. I also encourage you to reflect on the times when you may have been the victim of racism, injustice or discrimination yourself, and if you have not, I challenge you to imagine how it might affect you. If during your racial awakening journey you discover, like me, that systemic racism is indeed a public health threat, I ask of you that you play a part in ending this racial injustice and that you join this global movement. The ideas above are but a small step towards bringing about desperately needed change.
The author would like to thank his many reviewers, whose opinions, time, and input gave this piece direction and breadth, and without which this effort would have not succeeded. Special thanks to Jamie LaBuzetta for her dedication and commitment to this piece.