On the morning of George Floyd’s funeral less than ten miles from our medical center in Houston, I was avoiding the word “Black.” Despite wholehearted pride in the strong Black presence in our community health center’s physicians, staff, and patients, I felt a loss of words that Tuesday morning. There was simply too much pain, grief, and rage in our community.
I was thankful my first clinic visit was a telephonic encounter; those are usually quick. As is habit for our predominantly Hispanic population, I instinctively dialed a Spanish interpreter before even opening the patient’s chart. I could try to convince you this routine wasn’t just because the patient’s name was Maria, but nonetheless, my assumptions were upended as the patient’s preferred language in the medical record stated “Portuguese.” I consciously did a self-check and resolved not to commit any further assumptions – though I was curious if she was perhaps Brazilian or Indian.
The patient was new to our system and requested a refill of her beta-blockers. After briefly commiserating the frustrations of virtual care in the COVID-era without a blood pressure machine at home, I hopped onto a second soapbox. When we didn’t know better, millions of Americans with hypertension were placed on beta-blockers for uncomplicated high blood pressure. Over the last decade, we’ve learned that other classes of medications are safer and more effective. After reviewing the middle-aged patient’s medical history, I broached the topic that another anti-hypertensive agent should be considered.
“Especially since I can’t see you over the phone, would you mind answering whether you identify as Black?” I asked. We probably cringed simultaneously. I usually preface this inquiry with an explanation that the thiazides or calcium channel blockers were shown in a landmark trial to lower blood pressure more effectively in Black or African-American patients. She likely winced that a simple pharmacy refill request turned into an unanticipated discussion about race.
“Eu sou branco …” she began before the translator kicked in with, “… I appear white but am born in Africa.” Determining this patient almost certainly did NOT fit the JNC-8 label of “Black,” I started to ask the next question about family history of kidney problems or diabetes. She persisted on the initial question. “I am Christian; I am from Angola; I do not smoke,” she asserted.
Unsure what exactly to do with these facts, I thanked her for the additional information and tried to move forward again. She insisted, “But if you think I should be on a Black medication for my blood pressure, I will take it.” Gosh, I royally bungled this. I fumbled over some words of apology and clarification that anyone could take any medication. She said she trusted me; I was the doctor. She was just a nurse. “A nurse?” I remember internally exclaiming. Then she definitely knows about all these classes of medications and already selected one she was happy with.
“You know, I’m happy to just refill the metoprolol,” I salvaged while lamenting having even let race enter this exercise at all. Even after re-reading the expert guidelines and original clinical trials, I’m still not sure what “Black” in medical literature means. Did participants self-identify as Black? Did they need ancestry from Sub-Saharan Africa? I’m pretty sure I wouldn’t label Elon Musk’s son, X Æ A-XII, as “African-American” even though the Musk family has been in South Africa for generations. Why am I labeling patients at all?
After completing the visit with as much cultural humility and professionalism as possible, I started to unravel. My mind nose-dived into the quagmire of health disparities. My Harvard IAT depicted a strong preference for Black women. Surely that makes me somewhat less likely to perpetuate the poorer health outcomes that BIPOC patients experience?
I recently acknowledged the truth about race in the medical literature. “Race is not a biological category that naturally produces these health disparities because of genetic difference,” academic scholar Dorothy Roberts writes. “Race is a social category that has staggering biological consequences, but because of the impact of social inequality on people’s health.” By routinely using calculators that inexplicably involve racial parameters (e.g., GFR, VBAC risk, FRAX, and PFTs), am I closing or widening disparities? I understand “color-blindness” presents its own drawbacks, but I feel complicit using tools that participate in structuring opportunity and assigning value based on a social interpretation of how one looks.
The last time I avoided using the word “Black” was in the wake of Freddie Gray’s murder in 2015. I’ve since come to agree with inclusivity leaders that cultural sensitivity and unconscious bias training are not enough. I can’t be afraid to say “Black” when asking about someone’s culture. That question can produce irreplaceably valuable insight into a patient’s goals, community, and preferences. Without that knowledge, what kind of healing am I providing? Highlighting race as a social construction is a powerful springboard to challenge everyday racism in our classrooms, educational and research institutions, and clinics.
I was reminded this month that being a good doctor is hard. Even if one wielded flawless diagnostic accuracy, communicating effectively with patients requires a lifelong commitment to connecting with and relating to people. When it stops being hard, is when I should worry.
Arindam Sarkar is a family physician.
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