DG: Hey, It’s Dan.

We’ve got a special episode for you this week produced by STAT News…it’s their relatively new podcast Color Code hosted by Nick St. Fleur.

Color Code talks with physicians, patients, historians, and others about the history of racism in health care and how it impacts people of color and underserved communities. We’re excited to bring you this episode and hope you enjoy it.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

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Nick St Fleur: Go right ahead.

Jerrel Catlett: All right, Rebecca, so I’m going to walk you through the case. So you’re going to have a 20-minute encounter with a standardized patient where you and an actor, pretending to be a student, are going to enter the room. And you both are going to do a preoperative blood draw ahead of a surgery that the patient’s going to have in a few weeks. So during that session…

St Fleur: Jerrel Catlett is a second-year MD/PhD student at Mt. Sinai in New York. He’s taking part in a fellowship designed to help dismantle racism in medical schools. As part of the fellowship, Jerrel is creating an interactive workshop for students.

Jerrel: So during that session, your patient is going to make discriminatory comments toward the student actor, and your goal is to use the framework that we learn in class to de-escalate that tension and complete the blood draw. So what are some things you might say to the patient if, say, they aren’t comfortable with your colleague doing that blood draw?

Rebecca Zhou: I trust the student’s judgment. We both received the same training on how to do this procedure in our coursework, so there’s no need to worry that they’re any less skilled than another student who would otherwise be doing this.

St Fleur: Jerrel and his classmate Rebecca role-played one potential scenario for the Color Code team. The exercises in this workshop will help them practice handling situations in which they may see or experience discrimination in the hospital.

Jerrel: And this is something that, like Rebecca said, we aren’t really trained to actually deal with in a mistreatment sense. We might hear it; we might experience it; but because of our position in the medical hierarchy, where we are just students, we have to defer to residents, who defer to attendings, who – the attendings were never trained on this type of thing. So they don’t know how to actually support their staff of color when something like this actually happens. So if we can train students, those students will become the resident and then the attendings who do know how to properly make sure that, when someone experiences that type of racial trauma, that discrimination, they aren’t the ones who have to advocate for themselves.

You have an entire community of people who know what needs to be done, how to support that staff member – that health care worker – and successfully kind of make sure that the patient knows that that behavior is not appropriate, while also making sure that the staff member themselves is taken care of.

St Fleur: Jerrel is trying to immerse participants in scenarios that are drawn from real-life experiences that doctors of color have shared with him.

Jerrel: Okay, great, and what’s something you might say if the patient’s being really aggressive with their racist comments and won’t let either of you continue the exam?

Rebecca: I might say, “I’m not comfortable continuing this interview when you use that language towards my colleague and I. We’re going to step out, and our attending will take over from here.“

Jerrel: This process directly impedes on their learning experience. And so it’s something where you can recuse yourself and say, “My attending will take over from here.” And so that’s something that we in our framework have devised as things that are appropriate to say. There are 120-140 medical students per class. People are going to come up with a lot of different creative ways that we’ll learn from as we’re beta-testing the case. And that’s part of my project, too.

Rebecca: Because sometimes when you’re faced with something like this, you might know how you want to respond, but you don’t necessarily have the words immediately at your disposal. So I think this was great.

Jerrel: All right, so that’s what – kind of, what we would talk about…

St Fleur: This is Color Code, a podcast from STAT. I’m Nicholas St. Fleur, a science & health reporter here. And over 8 episodes, I’m taking a look at the hidden and not-so-hidden forces behind our country’s stark racial health inequities. This is Episode 3, where we’re taking a look at the fight to integrate antiracism into medical education across the country.

Students are at the bottom of the medical hierarchy. But when it comes to social justice work, they’re often the first ones to spark change. Jerrel and others like him want to make their institutions safer and more welcoming for future generations. Though Jerrel says that his institution is very diverse, there are instances where he and his Black classmates have faced micro-aggressions that have left them shaking their heads.

Jerrel: And so it’s something where I do feel like there’s this thriving community of physicians, nurses, students from multiple years, who we all talk about these things. We all kind of compare notes and say, you know, “What did we just experience? Did this just happen? Did we have a class where someone said that the Tuskegee syphilis experiment was a positive thing?” That did happen.

St Fleur: I’m just curious – I’ve never heard of anyone say Tuskegee could have been positive. What was the argument they were trying to make? And you know, you don’t have to name names or anything, but I’m just legitimately curious.

Jerrel: We were talking about syphilis, the pathophysiology of how syphilis affects the body, the different stages of it. And toward the end of it, there was a question about the Tuskegee experiment. A guy had asked, “Does anyone want to dive into this and briefly summarize what it was?” I, as someone who studied this type of thing in college multiple times, was like, “Sure, I can give a minute diatribe about how awful this was.” And the guy was like, “Yeah, sure. You know, it also had its benefits, too, because it was doing some sort of targeted trial toward a vulnerable population that experienced this disease disproportionately,” which is a fundamental misunderstanding of exactly what this was, where sharecroppers had syphilis, and were told that they were being treated for it, but weren’t, and followed for decades as the disease progressed. And so that isn’t treatment. It wasn’t a trial. And so we brought that to the administration. They addressed it right away. We had an entire separate lecture made about this thing to dive into it more in depth that all students had to go to.

St Fleur: Jerrel’s work is just one aspect of a larger push towards antiracism at Mt. Sinai and other medical schools across the country. Jennifer Dias is another student at Mt. Sinai, spearheading these efforts.

Are you by the hospital right now, in terms of living? I hear a siren. Is that what you’re always hearing? Are you always – always have ambulances around? Tell me.

Jennifer Diaz:  Yes, sadly. So I’m sorry if that ruins any of the recording. 

St Fleur: No, not at all! Not at all. So you live by the hospital… 

She’s taking a break from classes after her second year to establish the Anti-Racist Transformation in Medical Education program, also called ART. The national effort provides a framework for how to incorporate anti-racist values through every stage of medical education. This year, ART ushered in its first class of schools, which included 11 medical schools, from North Carolina to Arizona.

What is it exactly you and your colleagues are doing at ART, and why?

Jennifer: Many institutions have said, “We need to be anti-racist, and here’s what we need to change.” But people don’t like when change happens to them, right? You don’t get buy-in if you tell people, “Hey, this is what you got to do tomorrow.” Because they’re like, “Why? And why did this affect me?” And so it’s taking some of the social science principles of how do you prepare people within an institution to change – because institutions don’t change; people do – and applying that to medical education and making it bias free or racism free.

St Fleur: And is that through curriculum? Is that through trainings. What is it you’re physically doing to incorporate that change?

Jennifer: So at the end, both. I would say we’re not going to train our way out of racism. So we can’t just say, “I went to this training. Check. I’m anti-racist.” It’s the idea that we can make a plan in terms of what we’re changing. But you have to have the agility to a) expect that there’s going to be unexpected consequences to your changes. And then b) there’s plans to course correct and also engage with the community in a way that they’re also involved in what is changing and how it’s happening.

St Fleur: Jennifer sees ART as an early step for institutions to transform their whole culture, including their practices and their policies. At times during the year, representatives from these schools get together to debrief on their progress.

Jennifer: I would say the first session that we had, it felt like we were at church, not going to lie. Like, we were getting “Amens.” And, you know, a lot of people just – it’s just the synergy of so many people across the country really coming together to say, “Not only could we have the ability to impact what’s happening in our schools, but then all of a sudden we are impacting so many other pockets.” Some schools are able to say, “Hey, well, this is happening at this other school. So are we going to hop on this change train too, or are you going to be left behind?”

St Fleur: It’s pretty nice to hear when anti-racism work can be so communal and healing. But there are also significant barriers to doing this work.

Jennifer: I would say the resistance is always present. And fear – I mean, quite frankly, is one of the biggest aspects of white supremacy culture is to make you scared of doing what you want and being yourself and telling your truth.

St Fleur: For anyone doing this work, there’s still a constant threat of targeted backlash. 

It’s funny. While I was, you know, preparing for this interview and just preparing for my week over the weekend, I was just watching TV, and who pops up but you! [laughs] You were on a commercial. I was just like, “Hey, I’m speaking to her in a couple of days!”

Michelle Morse: I know! The commercials have been getting some reactions – that’s for sure. 

St Fleur: I’m sure they have… 

Michelle Morse is a physician and the Chief Medical Officer of New York City’s Health Department. And she currently stars in some local Covid safety commercials. But she used to work in Boston as a hospitalist at Brigham and Women’s Hospital. Last spring, she and a colleague published a paper for the Boston Review called “An Antiracist Agenda for Medicine.”

They wrote about a study that looked at how providers at their hospital were caring for patients with heart failure. They found that white patients with heart failure were more likely to get specialized cardiology care, while Black and Brown folk with heart failure were more likely to get care on non-specialized, general medicine floors. They called for the hospital to rectify the unequal treatment of patients of color. Eventually, conservative outlets caught wind of the paper.

News Clip #1: …Meanwhile, critical race theory now coming for your healthcare. Instructors at Harvard Medical School going to use race as a determining factor when treating patients for heart failure…

News Clip #2: …breaking tonight. A top Boston hospital’s considering offering race-based preferential care in an attempt to…

St Fleur: On a Saturday this past January, about two dozen members of a neo-Nazi group marched outside Brigham and Women’s Hospital.

News Clip #3: …In the months since, the Worcester-based group of neo-Nazis has been protesting Morse and Wispelwey, accusing the doctors of pushing a “blatant anti-white genocidal policy.” But after the group’s latest demonstration, hundreds of doctors from around the country have shown their support for the anti-racist efforts, signing onto a letter…

Michelle: So I was not in Boston when this march happened. However, I heard about it through friends, and a couple of days afterwards actually saw a tweet that showed a picture of a flier that had my name and face and my colleague, Dr. Wispeley’s name and face as well. And so I think that’s the point that it became particularly real, let’s say. And it was a really profound experience to see my face on this flier. It felt quite surreal.

St Fleur: Across the top of the Flyer in big, bold white letters, it says, “NO ANTI-WHITE POLICIES IN HOSPITALS.” Below the faces of Dr. Morse and Dr. Wispeley, the text basically reads that what these doctors are doing is injecting critical race theory into these hospital policies. And it’s just basically spewing some more neo-Nazi propaganda. And at the end, in big bold, letters, it says, “WE WILL NOT TOLERATE THE GENOCIDE OF THE PEOPLE WHO FOUNDED THIS CITY.” It’s just super intimidating and scary. For Dr. Morse, when she learned of the rally, she knew exactly where the white supremacists were marching, where they were spewing this hatred.

Michelle: I myself walked into Brigham and Women’s Hospital through the entrance where the protests happened, you know, about a million times between 2008 and when I transitioned here to New York City. So it’s a very familiar space to me.

St Fleur: The residency program at Brigham had made admirable strides to become more diverse, Dr. Morse was telling us. But an institution can only do so much to fashion itself as antiracist. It can’t bar racism from the outside world.

Michelle: And so I also thought, “Oh, my goodness. We have the largest number of people of color in the intern class in the internal medicine residency. In the year that they start, there are neo-Nazi groups marching on the lawn of the hospital.” So that was profoundly concerning.

St Fleur: To Michelle, the march was alarming. But it also matched what she saw in other parts of the US.

Michelle: What the response to the neo-Nazis is clearly – and what the public needs to hear and what providers need to hear – is that the current reality of our country is white supremacy, and that’s the problem. And it’s not about the solutions to health equity. It’s really about the fact that the current state is profoundly unjust and unfair to people of color and has been since the history of the founding of this nation. So although it was jarring – and confusing, quite frankly – and, more than anything, alarming, in my opinion, what we need to be talking about is describing all of the data, experiences, and evidence that we have, showing that the current state of this country, when it comes to health and social well-being, it is white supremacy, and that’s what has to change.

Gorenstein: But what happens when the enemy is within? We’ll return to Color Code…after a quick break.

MIDROLL

Gorenstein: Welcome back. We’ve turned over the feed this week to our friends at STAT News, featuring an episode from their newest podcast “Color Code”. Here again is host Nick St. Fleur exploring how doctors of color are coping with racism in medicine.

St Fleur: But racism, as we know, isn’t always as obvious as mobs of white supremecists shouting at rallies. Backlash to antiracist work can also come from inside a medical institution, and in some ways, that’s harder to fight. This is something Dr. Aysha Khoury knows well.

So I’m kind of just going to let you start wherever you would like to start, as it pertains to your instance, and what happened here if you want to set the scene for us?

Aysha Khoury: Sure. So, I was asked as an instructor – sorry, I get triggered by it, so I’m sorry. If you could give me a moment, I’ll start over.

St Fleur: No, of course. Of course. Take your time.

Aysha: My heart rate just went way up.

St Fleur: In the summer of 2020, Aysha was a professor at Kaiser Permanente Medical School in Pasadena, California.

Aysha: I am a child of immigrants. I was born in Canada, but I’ve grown up in the United States since I was eight years old – in Atlanta, since I was eight years old. I’ve never been fired, never. I’ve always considered myself a hard worker.

St Fleur: That August, all the instructors, including Aysha, were asked to lead a discussion with their groups of 8-10 students about race and gender bias in medicine.

Aysha: As a Black American woman physician, I felt that this was a conversation that I could have at a different level than some of my other facilitators because I know what it means to be a Black woman in our health care system. I know what it means to be a Black woman physician in this health care system. And so I brought a lot of my personal experiences to the discussion. I promised the students that what was discussed in the classroom would remain confidential, but I will say that it was a heartfelt class. It is not easy to discuss race. It can make people uncomfortable on all sides. I will say the experience as an attending physician being hired to teach a class that is diverse, but to also speak about race puts me in a very different position. But I will say that at the end of the class – and I am a spiritual person, so I will use the term “sacred.” And I felt that the environment that was created in the class was sacred.

St Fleur: After having such a meaningful discussion with her students, Aysha was shocked by what happened next.

Aysha: Chadwick Boseman, I’d just read that he died. I was actually out to dinner with some of my colleagues, who congratulated me for the class that I had when I told them some of the discussion that was held. But they were with me when I saw that I missed a phone call. And so I asked them to stay with me because for the Dean of Community Affairs to reach out to you after hours is unusual.

St Fleur: She was told that someone had complained about something that had happened in class that day. And then, she was immediately suspended.

Aysha: So as someone who, since fifth grade, wanted to be a doctor, and then I was in 11th grade, wanted to be a teacher. I found myself unable to do the two things that I love, and that was an extraordinarily stressful time and continues to be as I’m suing the school.

St Fleur: Eventually, she took to Twitter to write out her thoughts on the experience. She felt if she had stayed quiet, it would have allowed the institution to tell its side without her getting the chance to voice hers.

Aysha: At the time, I was really just trying to work through all that it meant to not consider myself an educator if I didn’t have students and consider myself a physician if I didn’t have patients. And through that time, I was working through this process with my pastoral counselor. And the day that I ended up sending my very first thread with only 12 followers was the day my pastoral counselor said to me, “We don’t understand the power of our own stories.” And I think it’s very easy, especially when you’re in medicine, because I think there’s a certain personality type of medicine – that kind of, “Keep your head down; do the work; grind” – that we don’t necessarily appreciate our own experiences. And so I wrote the thread really just also so I wouldn’t feel complicit in my own trauma.

St Fleur: Soon, her tweets went viral. She received an outpouring of support. And other folks shared their own concerns and experiences.

Aysha: I naively didn’t expect that what happened to me was something that was happening to other people.I came across a conversation on Twitter, and what struck me was a response that said, “We believe her because we know it’s true.” And then what was heartbreaking were the stories from young people, either pre-medicine, in high school, elementary school – through their parents, who were saying, “This is what scares me about going into medicine. I don’t want this to happen to me. I have this dream, but I see what happened to you.”

And so part of the reason that I continue to stay public is because there has to be a change. You know, I just had a patient, and I told her – I said, “Next time you come, bring your daughter.”

Her daughter wants to be a surgeon. Her daughter’s in the eighth grade. And in fourth grade, she has a career day, and a surgeon came and spoke, and now she wants to be a surgeon. For me, I decided in fifth grade, so I know it can be done.I don’t want her to feel that just because of an experience of someone losing her job, she can’t pursue her dream.

St Fleur: And tell me about the changes that you feel need to be made, and who do you feel needs to be at the forefront of those changes?

Aysha: I think the people responsible for those changes, first and foremost, are the people who are responsible for medical education and residency education, and that’s the LCME and the ACGME. If you go to their website, there is anti-racist language; there is language that suggests they understand the importance of diversity. They very clearly share what it means to become a physician and what values a physician should have. But I find those institutions fairly lacking when it comes to demonstrable action that protects residents.

St Fleur: And Dr. Khoury, you know, what I hear a lot of in this space and you yourself brought it up is you want action as opposed to – as people have said to me – “lip service” or something, that kind of, you know – “DEI anti-racism theater,” as some institutions do do.

I was reading a Forbes article that had written about your experience, and they did get a statement from Kaiser. I’m wondering what your thoughts are on what kind of Kaiser has said. If you don’t mind, I’ll kind of read what they had said, which is, “Dr. Khoury was not placed on leave for bringing content related to anti-racism to the classroom or for sharing her experiences as a Black woman in medicine. Our faculty have been and will continue to be encouraged to relate these issues to classroom topics, and this has happened repeatedly since classes started in July 2020. Our school remains committed to being a leader in anti-racism and being on the forefront of issues related to equity, inclusion and diversity among medical schools.”

What’s your thought on that being their response to everything that has happened to you? And you said something to me earlier: “I believe it because I know it’s true.” What’s your response to what they said – their statement?

Aysha: I think the words could be very inspiring. The reason that I moved across the country from everything that I know is because I believed in the values that the institution has listed on their website. Leadership has to be proven in action. As far as the reasons for my dismissal, I’ve shared that letter on my Twitter account, and I did so boldly because I know it’s bogus. But I hope that they become a leader in anti-racism. I hope that there’s a change of heart. Early on, and still, I’ve encouraged institutions to engage in the restorative justice process when there’s an issue, and that’s a process that even ACGME has put forth as a way of managing issues, especially racism, gendered microaggressions in the workplace. And in part because it’s a process that will allow for wholeness. It’s not a process that’s punitive. It’s a process that requires accountability and transparency. I think that’s where real anti-racism leadership is going to end up being. It’s not just going to be because it was said. It’s ultimately going to be because of the actions that are taken.

St Fleur: Aysha filed a civil rights lawsuit against the Kaiser Permanente School of Medicine. It’s been a long battle, that was recently made longer when the judge granted the school a continuance, pushing the court date back another year. Since 2020, Aysha has moved from California back to Atlanta, Georgia, where she’s finding her rhythm again.

Aysha: Yeah! So I’ve actually returned to my alma mater, Morehouse School of Medicine. I have a clinical practice, and I am happy to be part of faculty that’s educating students. We just had a wonderful Match Day. We’re still celebrating. And this has been a returning home for me all the way round. I’ve returned to my home city. I have returned to the home institution that has nurtured me, and it’s just lovely to kind of have landed here after the experience that I had.

St Fleur: Happy Homecoming.

Aysha: Thank you. [laughs] Some people actually sent me those messages: Welcome home!

St Fleur: This push towards antiracism in medicine and medical education – it’s fraught with hurdles. It’s hard to change institutions in America, especially when issues of race and racism are at their core. Yet despite these obstacles – whether they be the hateful words, spewed from the mouths of neo-Nazis, or thorny backlash from the academic institutions themselves – what we’re seeing – this activism led by students and educators and health care professionals – it’s planting the seeds that could one day blossom into an antiracist future in medicine: one where everyone gets the care and the respect they deserve. Now, that’s not to say that antiracism alone will bring us to health equity. There are several other structural changes that need to be made in our health care system before we reach that point. But ultimately, efforts like these – they’re a step towards achieving that goal of health equity.

Gorenstein: Thanks again to Nick St. Fleur and the rest of the team at STAT for letting us run this episode today. Subscribe to the podcast Color Code wherever you get your podcasts. There’s additional info and links for this podcast on our website. 

I’m Dan Gorenstein, and this is Tradeoffs.