I never gave much thought to racism until the Black Lives Matter movement, let alone dwell on my role as a physician with the power to contribute to the marginalization of Black Americans. I didn’t think that I needed to do so; I considered myself an ally by default. I am a South Asian female, a minority on two counts. I, too, have felt the sting of microaggressions in the white boys club of our medical fraternity. I have training in public health; the data on racial bias in medicine is not novel to me. I’ve chosen to practice medicine in a community of primarily Black patients. I have Black friends. I voted for Barack Obama, have taken the Harvard implicit bias test twice, listened to Childish Gambino’s, “This is America” on repeat when it was released. I consider myself an imperfect, but ultimately good person. There is no way that my actions could contribute to the systemic oppression of Black Americans in our health care system. Right?

While in residency, I vividly remember taking care of a white woman in her 60’s who was admitted for ambulatory dysfunction. Her PCP had been prescribing decades of opioids for chronic back pain, and she subsequently required even higher doses while hospitalized. Our intern voiced concern about the increasing doses, and the attending chuckled at her innocence. “Give the patient pain meds,” he said. “Addiction will not be a problem. She’s a nice lady.” We received sign-out the next morning that she required two doses of naloxone, and I saw her later in clinic after another admission for opiate overdose. To be fair, she was a very nice lady, but addiction does not choose based on race, age, or who seems “nice.” The same attending declined IV pain medications earlier that week for a Black patient with severe pain from osteomyelitis and a Hispanic patient with nephrolithiasis, which resulted in the patients leaving AMA. They had no history of substance abuse (although this, too, does not imply that their pain should have been undertreated). Though I noticed a distinct pattern of bias, I didn’t speak up. Research has consistently demonstrated that a Black patient’s pain is undertreated when compared to their white counterparts. The unsaid but palpable undercurrent is that Black patients are more likely to be pain medication seeking and that their medical conditions are somehow borne of their own poor choices and noncompliance.  In hindsight, I have been a participant to other scenarios in which, as an eager learner, I mirrored the implicit biases of my teachers and ultimately contributed to unfair treatment.

I have also been complicit in acts of racism towards my fellow physicians. I remember hearing my favorite attending poke fun at a Black co-resident for ceremoniously, formally introducing himself as “doctor” with colleagues and ancillary staff. I had watched this co-resident get mistaken for custodial staff, medical transport, and food delivery services, and guessed this to be the motivation behind his desire to be called by his earned and deserved title. I smiled at the joke, wanting to appear good-humored and never spoke up. Last winter, I watched a Black male attending physician get stopped in the lobby of our hospital because he could not locate his badge in his large down coat. The security guard did not stop me and the other white workers who walked in together; none of us had shown our badges. I walked away without speaking up. It was easier to move along than to stand up for the injustices I saw happening before me.

As physicians, it comforts our scientific sensibilities to quantify the inequality into something tangible. It is easy to hide behind the evidence and cite the things we know to be true. We know that Black patients are disproportionately affected by HIV; Black men who have sex with men (MSM) comprise 20 to 25 percent of those with HIV despite making up only 1 percent of the population. We know that Black women are 2 to 6 times more likely to die from complications of pregnancy than white women, depending on where they live. A recent New York Times piece summarized the chilling data surrounding racial disparities in COVID-19 infections; “Black people are three times more likely than white people to contract the coronavirus, six more times likely to be hospitalized as a result and twice as likely to die of COVID-19”. Still, the research leaves unanswered questions. The differences in life expectancy for Black Americans cannot be attributed to socioeconomic status and education alone; at every level of education and economic status, whites live longer than their Black counterparts. What if the unaccounted difference in the health and mortality is iatrogenic? What if, after gathering the evidence that systemic inequality exists in health care, we have been congratulating ourselves on this revelation in the comfort of our ivory tower, avoiding the more difficult question- how are we contributing to these unequal outcomes?

As a profession, we have come a long way from our blatantly racist treatment of Black Americans. Today’s racism in medicine, though subtler, is still pervasive; despite growing evidence that race is a social construct rather than a biological one, our patients are affected by our underlying racial biases. It prevents them from receiving equal outcomes in the cardiac standard of care or utilizes an outdated modality of measuring kidney function, which can result in inequitable transplant outcomes, simply because of the color of one’s skin.

I have come to realize that gathering the data on inequalities in health care and raising awareness is insufficient. I am convinced that silence is complicity when it comes to acts of racism. It is a good start to show solidarity with White Coats for Black Lives, but the symbolism is lost if we cannot commit to the work of introspection and the responsibility of restructuring a broken system. So, if I desire systemic change, I must first change myself. I must pledge to speak up, be vulnerable, be comfortable in my discomfort, and advocate for those who are oppressed. If you have had the benefit of the white privilege that comes with the white coat, I invite you to do the same. Let’s get started. We have so much work to do.

Niharika Sathe is an internal medicine physician.