How physicians can be activists [PODCAST]

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“We dealt with the death, uncertainty, and fear of COVID-19 with a stiff upper lip. But our hearts broke when George Floyd was murdered by the police on May 25. George is a symbol of an immense problem. A study reported that one in every thousand Black men can expect to be killed by the police. One in every thousand! Racially directed violence by the police is a public health problem. Clinicians cannot be silent. Clinicians will not be silent.”

Karim Khan is an infectious disease fellow.

He shares his story and discusses the KevinMD article that he co-wrote, “White Coats for Black Lives: How to transform anger into action.”

This episode is sponsored by The Nuance Dragon Ambient eXperience (DAX). The Nuance DAX solution makes it possible to forget the tech-toggling and reduces documentation burdens no matter how or where care is being provided. 

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Karim Khan. He’s an infectious disease and addiction medicine fellow, and he co-wrote the KevinMD article “White Coats for Black Lives: How to transform anger into action.” Karim, welcome to the show.

Karim Khan: Hi, Kevin. Thanks for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Karim Khan: I came to medicine from a background of activism, which started early on for me, back in college. I got involved in a number of student activism groups working on issues that ranged from homelessness to police brutality to student tuition to workers’ rights to immigration rights. I dabbled in a whole lot in college, and in the meantime I was very interested in medicine and doing my pre-med coursework. I applied for medical school and came to medical school with the frame of mind that I wanted to work with people who were disenfranchised and do something where I could help people.

A lot of this coincided with the homeless work that I was doing. I had become very involved in a nonprofit that helped with meal sharing and local housing advocacy. And so in medical school I got introduced to the idea of street medicine and homeless medicine, and that’s really been one of my primary passions.

As I moved on through residency in Chicago, I got more involved in street medicine, but in Chicago I also got more involved in the communities where I was working, on the West Side and on the South Side. I developed an interest in infectious diseases and picked up a primary care HIV clinic down in West Englewood, on the South Side of Chicago, and I really started to see firsthand some of the inequities in our health care system and how they interact with race and power structures. I saw firsthand the role that clinicians can play in continuing those systems of oppression, or in undermining them and creating something new and beautiful and inclusive.

And so that’s been a primary passion of mine going forward. I applied for infectious disease fellowship and found myself at a really good match at Boston Medical Center, doing a combined infectious disease and addiction medicine fellowship focusing on folks who are at the intersection of these two worlds. Oftentimes that’s people who inject drugs and have complications from their injection practices. It’s not entirely just that population, but there’s a huge intersection between housing status and race and gender and trauma and access to health care, access to food. All of these structural and social determinants of health that, coming up through my education, I had grown very interested in and had been working in became available as a field of medicine for me to practice in. And so I’ve been in my fellowship now for a little more than a year here in Boston.

Kevin Pho: Can you share from your experience some examples of how racial injustice affects the patients that you see today? Can you paint us a picture?

Karim Khan: Yeah, most definitely. I think probably the most pressing and relevant example right now is COVID, and that’s on everyone’s mind. It has been, unfortunately, on everyone’s mind for the past close to a year now. What we saw here in Boston was a large first wave shortly after New York’s wave. We saw entire communities seemingly decimated, and what we saw were communities largely of color. We saw communities in East Boston, in Roxbury, in Mattapan, in Jamaica Plain, in these neighborhoods that, if you’re familiar with the Boston area, are historically communities of color. They are communities that experience a lot of poverty. There’s a lot of vibrant culture and love there, but there is a lot of structural violence, and there’s a lot of trauma on the streets.

What we saw specifically at my hospital was large numbers of people coming from these communities, suffering and experiencing structural inequities compared to other parts of the city and other hospitals in the city, and having horrible outcomes with COVID, at least initially. I mean, thankfully, we actually had relatively good outcomes in our hospital, and we were very proactive in engaging our communities and developing protocols. But we were just witnessing firsthand the way in which research trial access was granted, not just in Boston but across the country: who is solicited to be in these trials, whether that’s for IL-6 inhibitors, back in the day when we were talking more about that, or remdesivir; who gets access to remdesivir; who gets access to vaccines. We saw firsthand communities that do not historically have power in traditional frameworks of power not have a voice and be wholly disenfranchised, and not be granted opportunities to have access to these potentially lifesaving treatments for COVID. And there were incredible frustrations within the health care community, of wanting to do something for our community when we did not have access to these resources.

And thankfully, we did see things change, at least here in Boston, around the time when people started calling out the inequities and the racial disparities in the way in which these resources were being distributed. We saw research trials starting to actively solicit and recruit from our communities, and we saw supplies in the form of remdesivir going to our communities. But it’s something that is still very fresh in my mind and in my colleagues’ minds, that the communities of color in our city, and I think, based off of what I’ve read, in many cities throughout the U.S., did not and do not have the same access to health care, and quality health care, that other communities, perhaps white communities, more resourced communities, wealthier communities, do.

And so I think that’s something that is very much on all of our minds. Paper after paper is coming out about the racial inequities and COVID outcomes. I think it’s super clear, and unfortunately an excellent example of how racial inequity can negatively affect our patients and our outcomes, and also contribute to physician burnout and stress for the people who are trying to do their best to take care of these communities.

Kevin Pho: So let’s now transition into the KevinMD article that you co-wrote, “White Coats for Black Lives: How to transform anger into action.” Now, for those who haven’t read your article, can you walk my audience through it and perhaps share the story of why you decided to co-write it?

Karim Khan: This article came into our minds, myself and my co-fellows, who are the co-authors, around the end of May, beginning of June. It was basically after the murder of George Floyd, set against a backdrop of incredible frustration in this COVID pandemic, and realizing there was a pandemic of racism going on at the same time. We were feeling entirely helpless, seeing that we could not get our patients access to these treatments and so forth, like I was saying, and then seeing the inequities and the racism and the police brutality, and frankly lynchings happening on the street without trials, and seeing our communities in so much pain and seeing our colleagues in so much pain. We felt that we needed to do something.

And here in Boston, as in many places throughout the country, movements erupted. Movements have been ongoing, and I think that’s something we need to bear in mind: These communities have been organizing for decades, if not longer, and we can support them. And so what was going through our minds is that a lot of us in medicine do not come from backgrounds of activism. We are not super familiar with the communities that we practice in, and if we’re practicing in a safety-net hospital, oftentimes we don’t live in the communities and we don’t experience the traumas that they experience, and so we don’t entirely know where they’re coming from.

And so we struggled with what we can do when we see something horrible happening and we want to help out. We are privileged to have a certain set of experiences and skills that we can contribute that not everyone can contribute. As health care workers, we can provide access to health care. We can help out with these things. As infectious disease physicians, we’re able to help provide information on how to stay safe while protesting, from a COVID perspective. I mean, a year ago, no one would have thought that we’d need to think about how to safely navigate massive street protests in the midst of a pandemic, but that suddenly, in June, became an issue.

And that was where we came from, and that was what we were thinking about in writing this article: How can we provide some guidance to other health care workers who are feeling similarly outraged, alone, isolated, but inspired to do something and to work together to help create justice in this world? And so that’s where this article came from.

And we ended up connecting with a lot of folks. We realized that there have been a lot of people, not necessarily just in the health care world but outside of the health care world, people with different professional backgrounds, amateur backgrounds, people who have been doing street medic trainings for protests for years, people who have a lot of experience, people that we can learn from. We linked up with a lot of these folks, and we realized this is not an arena that we are familiar with. If you want to come to the ER, if you want to come to the hospital, sure, we’ve got that. But out on the streets with these communities, we are people of privilege coming to learn from them and to help where we can.

And so it was really a case of giving some guidance on how you can get street medic training, training to provide basic trauma care on the streets for when people are getting shot at with rubber bullets, now getting shot at with real bullets potentially, tear gas canisters, what have you. Thankfully, Boston has not been that bad, but we’ve seen across the country varying levels of violence out on the street and a need for health care out on the street. And so that was one component of it.

But we also realized that we come from places of power and privilege, and it is our duty to address these structures of power. Historically, medicine has been white, it has been male, it has been propertied, it has been wealthy, and we need to fix that. And so we need to be out on the streets. And not everyone needs to be out on the streets, I get it. I’m an infectious disease person. I know that there are risks that come with being out on the streets, and I know that’s a decision everyone has to make for themselves. But if you make the decision not to be out on the streets, then certainly there’s still a lot of work you can do, and there’s a lot of work you can do within your own institutions. That’s where it comes to connecting with other folks at your institution who are interested in addressing racism and furthering anti-racist work, and working at the intersections of systems of oppression to undo them, frankly, and to create some sense of justice.

And so this article was really a culmination of a lot of emotion. How do we navigate being out on the streets and supporting communities? How do we navigate making our hospitals and institutions more welcoming and inclusive places, not only for patients but for trainees, for faculty? How do we recruit people? How do we make this a safer place for our environmental staff in the hospital? Anywhere you look, there are issues that we can work on. And so this is really where this article came from, and we were hoping to just scratch the surface and maybe inspire a couple of folks who read it to reach out to other people and start organizing.

Kevin Pho: Now, you mentioned that there are other ways to be involved in the movement other than going out to the streets and protesting. What are some of those other ways? Can you share more detail about that?

Karim Khan: Sure. So for instance, we have been involved in multiple committees and workforces here at our hospital addressing things such as trainee recruitment and graduate medical education and diversity, creating programs that people of color will feel comfortable in, and see people from their communities at, and want to come to. And that necessarily will change the culture of our institutions. It’s not an overnight change, but it’s something that will create change in the long run.

Similarly, looking at recruitment and retention and promotion practices among faculty, specifically within medicine. When you leave the world of MDs, then you enter the world of nursing, of environmental staff, of everyone that you can think of who works in a hospital, the clerk’s office, administration, and you think about: What are the labor benefits that people get? What is the racial breakdown of our departments, and how can we improve things? Can we look at our different departments and low-wage earners at our institutions and see that there is racial inequity in how these departments are staffed and how they’re paid, despite the fact that a hospital will not function without someone who can clean a bed after a patient is discharged?

There’s work being done to look at how hospitals internally police and how their public safety operates. How is security called on patients? Which patients is it called on? Is there de-escalation practice training? For us at Boston Medical Center, we see a lot of addiction. Thankfully, we have a lot of addiction expertise, but it’s something that’s always on our minds. And so: How can we better respond to addiction crises and mental health crises? And how can we avoid instances, and thankfully it hasn’t happened here at my hospital, where there’s an opportunity to de-escalate some sort of conflict, and what happens is someone gets hurt, someone gets shot, or something worse? And that happens, as we can see throughout the summer, not just in the hospital but everywhere. That happens day in, day out in these communities.

And so there is a whole lot of work that you can do. I think one of the most inspiring things that I have learned, and my colleagues have learned, is that we’re not alone. It can feel, especially when you’re at an academic center, a large academic center with a lot of different employees and a lot of different silos, that you don’t know what’s going on, you don’t know what to do, you don’t know how to get involved. But the first step is just talking to your colleagues, talking to your friends, and asking them: How are they feeling? Are they happy about what’s going on out in the world? Are they happy about what’s going on in their hospital? Do they want to see change? And from there, you get a group together and you can brainstorm how to change things. And that’s really how the snowball started with us, at least.

Kevin Pho: We’re talking to Karim Khan. He’s an infectious disease and addiction medicine fellow. He co-wrote the KevinMD article “White Coats for Black Lives: How to transform anger into action.” Karim, specifically with the Black Lives Matter movement, not everyone supports that. Now, what do you do as an activist physician when you encounter pushback against the cause that you support, specifically with patients and your colleagues?

Karim Khan: That’s an excellent question, and I don’t know that there is a 100 percent correct answer, and that’s probably why we see a lot of, at least, theoretical conflict and physical conflict in our country today: trying to figure out how we can bridge that gap and that divide. My personal feeling is that a lot of it comes down to experiential learning. I think we have unfortunately seen a world that has a lot of social media and these silos, where people are only talking to people who are like themselves. I think there is benefit that comes from reading books and reading articles and things like that, but I have also seen a lot of times where people have read the same article that I’ve read, but they come away with a different feeling or a different impression. And A, that is fine. That is part of being a free society. But B, I think it really comes down to experiential learning, and it really comes down to going out and seeing what these communities experience firsthand.

And I don’t mean being a tourist. I don’t mean going to the dangerous, poor part of your city or whatever to just drive around and watch. I mean go volunteer, go talk to people. You don’t have to volunteer in an anti-racism organization; volunteer in a food bank. Just learn about the struggles that people are going through. And I think for me, at least, I’ve realized how much, A, of course, there are systemic policies that are driving this, and then there is trauma as well. You can really get a sense, from just talking to people and learning how they live, about what is driving some of the problems that we as a society experience.

And then you can begin to engage with the Movement for Black Lives, and it is not a homogenous movement. There are a lot of different thoughts and philosophies within it, and there is a lot of space for growth. And so I think my piece of advice would be to go out and engage with these communities, and engage with them in a manner such that you want to learn from them: not that you’re privileged, not that you’re coming from a place of power, not that you’re wealthy, not that you’re educated. Really go and listen.

Kevin Pho: With your background in activism, what’s your number one tip that you can share with physicians who do want to become more involved, aside from what you said earlier in the interview?

Karim Khan: I think my number one tip, and I kind of did mention it earlier in the interview, but I can expand on that a little bit, is that the community has been doing this work. In academia, we love to think that we know everything. We love to think that our randomized controlled trials are the end-all, be-all. But, you know, communities have existed before evidence-based medicine. And don’t get me wrong, I love evidence-based medicine and I practice it, but communities have a lot of knowledge, and they’ve been doing this work.

I can guarantee almost anyone listening that if you’re in, certainly, a mid- to large-size city, there are countless organizations already working on these issues. This is not something you need to take up by yourself, or reinvent the wheel. This is something where you can ease in and you can learn from other folks who have been doing this for longer, and really get a sense of what’s going on. And so I think there is a fracture between academic medicine and the community. And I think realizing that, at least for me in academic medicine, the community knows a lot, and we have a lot to learn from them. And honestly, unless we do that, we can’t serve them. And I think ultimately most folks in academic medicine still want to serve the community.

Kevin Pho: And my final question: Do you have a take-home message that you want to share with the KevinMD audience?

Karim Khan: Yeah. My take-home message is talk to your colleagues. Talk to them at work; see what they’re feeling. These past eight months have been traumatizing for so many different reasons. People are struggling. Talk to them. There’s power in being together, and there’s power in realizing that we are not alone. This is true when it comes to the COVID pandemic. This is true when it comes to a pandemic of racism. This is true when it comes to housing. This is true when it comes to everything. And so talk to people and organize.

Kevin Pho: Karim, thank you so much for sharing your insight and expertise. Thanks again for being on the show.

Karim Khan: Thank you, Kevin.

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