“What’s the deal with your people?”
As a baffled second-year resident, I looked up through my scrub mask at the Caucasian female attending with whom I was operating. I had an idea about what she was referring to as I overheard her complain about a laboring patient while she was scrubbing with the other Caucasian attending who was operating in the room next door.
“She acts as if she has never had anything in her vagina, but clearly she has.”
This recently immigrated South-Asian patient, Aisha (identifying information changed), was like many that I had been asked to examine. She was a meek patient and, like any other woman in her first labor, she was scared and uncomfortable. She had a small introitus and had a difficult pelvic exam with an inability to relax her legs during the exam. She had always had pain with intercourse but was told this was normal. Looking back with more knowledge and expertise, she clearly had a hypertonic pelvic floor secondary to anxiety and fear resulting In vaginismus and likely had provoked vestibulodynia.
There were quite a few “Aishas” who I would encounter during my residency, and I always felt like the attending physicians’ involved would begrudgingly take care of “my people.” Yes, their exams were difficult, and each patient took extra time, but I found many of them did not receive the empathy and cultural sensitivity they needed in their health care delivery. Many of the patients were from a culture of deference to the physician, so, although they may have been uncomfortable, they “went along with whatever the doctor said.” As a young resident, I never felt comfortable with the stereotype but also did not feel brave enough to say anything to these physicians.
Truthfully, racial inequity exists in the delivery of health care just as it does throughout other elements of society. The “father of modern gynecology,” James Marion Sims, is a prime example of how the institutions that have existed for centuries have utilized endemic racial biases to unequally treat different immigrants and races. He is known for modernizing many surgeries, including vesico-vaginal fistulas, but did it at the expense of experimenting on un-anesthetized African slaves and poor Irish immigrants. It was a common belief that African women did not experience pain, and it made it easier to dehumanize these patients for the sake of the greater good, elite Caucasian women with similar problems. Even today, maternal mortality rates in the U.S. for African-American women is three to four times higher than Caucasian counterparts, even when correcting for education and socioeconomic status. According to the Institute of Medicine, there are still “quality chasms” that exist for minority groups in the United States owing to the lack of cultural competence by many health care providers and lack of education and understanding of certain underserved and under-represented groups. But in my opinion, it is a deeper problem than this. Racial inequality is experienced by many of us through many different institutions — law enforcement, education, and political systems, to name a few. Is it that much of a surprise that it spills over into health care delivery?
As a brown girl growing up in the South, I was subjected to a significant amount of racism. I always imagined, once I had attended elite universities, attended medical school and started practicing medicine, I would be less likely to see it and be immune to it. Working as a Muslim physician in the post-9/11 era, there were many times I would hear blatant racist statements or even subtle ones — during Ramadan when fasting, from certain patients and even from attending physicians. Whether it was a joke about terrorism, discussions about “towel-heads,” or opinions about their female patients, their pelvic exams or their status, these comments were often stated with minimal remorse. It never surprised me and for some doctors that I know, this discrimination is still endured now during the Trump-era of politics.
Nowadays, I work in downtown Chicago owning and operating a gynecology practice with one of my specialties being sexual dysfunction. As it turns out, based on my expertise and location, “my people” tend to flock toward me for their care and management. Maybe because of my background, cultural competence and experience, I now know “what’s the deal with my people.” I like to believe that being brought up with egalitarian principles and a general calling to serve those in need, I am able to deliver unbiased health care equally to my patients. I do not believe the entire health care system is broken when it comes to equality in health care delivery but I do believe our inherent biases impact how we perceive patients. Representation matters and knowing there are like-minded medical professionals is a start. Empathy and goodwill toward all races and socioeconomic backgrounds cannot always be re-taught to individuals but being aware of the discrimination and stereotypes are a stepping stone to breaking these barriers in health care.
Sameena Rahman is an obstetrician-gynecologist.
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