Managing day-to-day racism: reflections from a mid-career medic

Although the effects of racism on health outcomes are well explored, there is less discussion on how to manage interpersonal racism in daily life as a clinician. Yet, we know that this is common. The 2022 Medical Training Survey national report found that 15% of respondents had experienced or witnessed episodes of racism in the previous 12 months. Disturbingly, this figure was even higher (34%) for doctors-in-training who identify as Aboriginal or Torres Strait Islander people. Although the AMA statement on anti-racism states “Healthcare professionals have a right not to experience racism throughout their careers”, it is clear that this is not our current reality.

I am so grateful for my life and privilege, that focusing on my experiences of racial microaggressions feels self-indulgent. However, recent conversations with doctors-in-training highlighted that this is worth sharing.

The following are my personal racism first-aid strategies that I have found effective throughout my career.

If you are a medical student, or doctor-in-training from an under-represented group, this is for you. I want you to know that, although we all have a responsibility to work for system change, you also have a right to self-care in the moment, and this is vital to counter the burnout that racism induces.

If you are an ally, you may still find it useful for reflection.

A story

First, a story. My braided hair is often commented on. This uses extensions, takes 8 hours to do and lasts up to 8 weeks (answering most questions). I regularly wore natural hair in between braid styles while a UK trainee. Soon after my move to Australia, I chose to wear my natural hair to work. My ward-round took at least twice as long as usual. Patients, relatives and staff touched and examined my hair, with, or mostly without asking, and commented on it (“like wool, so soft!”). Initially, I thought the quickest response would be to succumb to their curiosity, but as the day progressed, I started to decline the requests. This was even more time-consuming, with more persistent requests. I then had to manage their disappointment. By the end I felt exhausted, objectified, like an exotic animal in a zoo, and somehow unreasonable for not accommodating everyone.

The experience was so overwhelming that to this day I rarely wear my natural, unbraided hair to work despite knowing logically that so many years later, I would be better able to advocate for myself and the experience would be different.

The people involved likely had no idea of this impact. Certainly, I did not feel comfortable to explain in the moment. The many bystanders likely took their lead from my passive acceptance and attempts to keep the peace.

Microaggressions

This is in the realm of what would be considered a “microaggression” although the impact over time is anything but “micro”. This behaviour is exhausting, even more so because it is widely unacknowledged.

Above is just one example of a myriad ways that racial microaggressions can show up in the workplace. Other examples include repeated questioning about our origins, qualifications and English language skills. It can also include well-meaning comments or complaints about previous interactions with “people like you”. Non-verbal behaviours that I have experienced include refusal to shake hands, not making eye contact, or directing every answer to my questions to another member of the team. These are magnified when the positive behaviour is performed easily with another team member. I have been misidentified by staff members, or not identified as staff at all despite wearing identification. This list is not exhaustive but illustrates the nuanced nature of microaggressions. Explicit comments about race are only the tip of the iceberg.

Repeated episodes of othering may contribute to a concept known as weathering or allostatic load – the health changes due to accumulation of stress over a lifetime. I believe that this contributes to workplace burnout for health care workers from under-represented groups.

How to manage this? Here are some strategies I have used and shared.

Assume good intent

I say this not because good intent is always present. If we want longevity for our careers, we need to save our energy, as responding is exhausting. You may need to let some things go, but you will also save energy for yourself and the interactions you want to prioritise.

Raise the issue when the intent is clearly not good

It might surprise people in majority groups to know that it is hard to speak up about even overtly racist behaviour if you’re in a minority. Fears about being considered over-sensitive or “playing the race card” can steal our voices.

If I need to speak up about minor issues in the moment, I will briefly mention it then change the subject, aiming more to signpost inappropriate behaviour, rather than enter conflict. Examples include:-

• “That’s not relevant, how about we talk about (something else)”
• “We don’t talk about/to people like that…”
• “We have lots of people of different cultures at this health service and they do a great job…”
• “I understand that’s how you feel but we don’t talk about or to our staff like that…”

Rarely, if the person is intent on continuing a racist theme, and it’s safe to do so, I will postpone the review saying:

• “That’s not appropriate, we’re leaving now, we’ll come back to review you later when were able to talk about your health”.

The goal here is to role-model providing care while setting a boundary.

This is easier said than done and we might feel we don’t get it quite right. There may be a degree of shame and self-blame if we haven’t had the perfect reply ready at the time. This drains our energy and does nothing for our goals of a long, happy, healthy career. Be kind to yourself and recognise that the perfect response does not always exist.

Support your team

As a consultant, many other team members will spend much longer with patients every day. If I am aware there has been some repeated subtle racist language/themes, I will update the nurse in charge and the multidisciplinary team, particularly to request that they support team members who are more junior or working out-of-hours, when there is less support around. This is not to label the patient; this is about clarity and consistency in response, enabling planning such as setting clear boundaries or expectations in advance.

One way to increase awareness of these events is to include them in health service-wide anonymous surveys such as the People Matter Survey and the Medical Training Survey if this feels the most comfortable way to raise them. Advocating for better understanding is worthwhile, in whatever way you can manage.

Be aware of stereotype threat

Stereotype threat is when our awareness of the risk of being judged negatively according to a stereotype impairs our performance in that situation. Feedback is vital and welcome for your professional growth. However, if feedback is personalised (“you are/were…”), poorly described or discouraging without practical steps to change, it may be worth considering if it has value for you. In the moment this is hard to see, so take time out to reflect on how the feedback relates to your goals. If in doubt, ask for clarification and examples of what was observed, to move away from their personal opinion and towards more actionable changes. Other people’s opinions of you do not need to become your identity.

Know your own value

Much of our career progression in medicine is based on external validation of our skills, competencies and attributes. This can lead us to base our identity and worth on external measures. In my teaching role, the concept of impostor syndrome is often raised. This is the experience of feeling like a fraud who is going to be caught at any time, that seems to afflict many of us in medicine at different times throughout our careers.

It is helpful to avoid basing our identity, worth and value on external measures whether positive or negative, and instead consider how we measure up to our own values, goals and expectations. Accept compliments and address negative feedback, taking neither too much to heart. Take what is useful to you in achieving your goals and avoid letting it define you.

Remind yourself what you have achieved

You have achieved many things that are not on your CV, write these down! This might include supporting your family and community while training, starting a family during training, working while training, moving states or countries, passing exams in difficult conditions, succeeding in the face of your own or a loved one’s serious illness or making difficult choices to realign priorities in the face of difficulties. Give yourself credit for how far you have come.

Surround yourself with “your people”

These need not and will likely not all be from the same group you identify with. Instead, they are people who appreciate you for you, regardless of titles/seniority, background, race, gender, sexuality or other characteristics. These people are rare, special; their support is precious. Keep them close and trust their instincts about you. If you tend to downplay positive comments from friends/family (as I do), learn to absorb and uplift them instead, and show your appreciation.

Turn the camera lens around

Redirect uncomfortable conversations so you are no longer the object.

In the face of questions about my origins, my first answer will be my most complete.

“So where are you from?”

“My parents are from Ghana in West Africa and I was born in England, I now live and work in Australia.”

Beyond this, if more questions arise, I will ‘turn the camera lens around’ by asking reciprocal questions such as:

• “Where are you from?”
• “Have you always lived in (insert suburb, town)?”
• “I was born in London, have you ever been there?”, (this works well, as most people have either been or want to go).

This helps me feel more of an equal conversational partner. As a bonus, people enjoy being asked about themselves and this can lead to great conversations!

P.O.W.E.R. framework

In her book Living while Black: The essential guide to overcoming racial trauma psychologist Guillane Kinouani talks of the P.O.W.E.R. framework for managing events in the moment. I believe it would have helped me in countless earlier experiences including the one I described. This includes preparing for anticipated microaggressions, observing your feelings, waiting to give yourself a choice about your reaction, breathing (exhale), these steps enable you to resist while making a conscious choice about your next steps.

Above all, be kind to yourself

I encourage you to do your chosen practice of self-care, find your personal fulfilment, take your leave and take breaks. Consciously consider and seek out the things and people that bring you joy. In the words of poet Audre Lorde “Caring for myself is not self-indulgence, it is self-preservation”.

Some thoughts for allies

There is growing encouragement for those witnessing behaviours to be an “upstander” or active bystander. If you feel confident to do so, please raise it. However, do this without any expectation of the person on the receiving end of the behaviour – you will have no idea of their journey with these events. They might say “It’s OK, I’m used to it” or they may say nothing at all, and that’s OK. They will still appreciate your consideration.

If you don’t feel able to speak up in the moment, consider checking in with them, a simple “I saw what happened, that was very wrong/off, are you OK?” and then listen to their response.

If someone shares an episode with you, you might feel upset on their behalf and push them to report it. Take their lead and ask them how they would like you to help them in this instance. Reporting is not a simple undertaking, and they will need to feel safe to take this step. Consider that if your only support is to push them to report, this may feel overwhelming rather than supportive to them.

You may be thinking and feeling many things about the event, explicit empathy is useful to let the person know that you believe and support them. This can be a simple and heartfelt acknowledgement such as “That sounds awful, how are you feeling?” followed by listening to their response. You could follow with “Is there anything I can do to help?” This type of acknowledgement and empathy from beautiful friends and colleagues has been invaluable to me over the years.

Conclusion

These are my reflections. I have not attempted to address wider issues of racism and particularly the institutional and systemic forms that harm our patients and vicariously or directly harm us.

Finally, as a doctor and as a mother, I am committed to remind every doctor-in-training that they are equally worthy, and they deserve a career that will value their dignity and self-esteem.

Dr Linda Appiah-Kubi is a consultant geriatrician at Western Health in Melbourne, and one of the directors of training for the Western Training Alliance and program lead in communication for the Victorian Geriatric Medicine Training Program.