THE ISSUES

 In addition to overt expressions of anti-Black racism, micro-aggressions recognize more subtle expressions of bias. Micro-aggressions are quite common in the current sociopolitical climate, as are overt expressions of bias and discrimination. Micro-aggressions leave Black physicians in a state of disequilibrium, with nowhere to turn. It nurtures a victim-focused identity in Black physicians and increases their self-doubt as the quality that earns them preferential treatment is an implied inferiority. It’s interesting that medicine, with its protocols, pathways, and years of training, has no blueprint for supervising physicians on how to address inappropriate comments toward the people training under them or working with them. This reluctance to address the existence of bias in a health care setting hurts patients and physicians because it perpetuates a culture of silence — or worse, denial.

Black physicians remain underrepresented in medicine despite national efforts to increase diversity in the health care workforce. Aspects of their cultural identity are ignored at work. Many perceive pressure to assimilate into the social culture specific to their institution while their workplace makes little effort to integrate aspects of Black culture into the environment. These experiences intensify a sense of “otherness” among Black physicians. Even the physical environments of medical centers can convey exclusionary messages to students and physicians. This portraiture can be seen as a visual demonstration of the profession’s values, which can be identified as whiteness, elitism, maleness, and power. Unfortunately, institutions are failing to create sustainable solutions to enhance diversity and inclusion. The strategy for creating a more diverse workplace commonly rely on the efforts of a few minority physicians and residents. Minority physicians and residents must often endure a 'minority tax', which includes taking on additional administrative tasks. These responsibilities are often disproportionately borne by underrepresented minority physicians in an attempt to advance diversity and inclusion initiatives, but these activities redirect valuable time away from duties required for academic promotion such as research and grant writing. Unfortunately these additional tasks are often not considered within the metrics for career advancement. Because of the transitory nature of residency, minority residents occasionally doubt that their initiatives will persist after they graduate. The success of diversity recruitment efforts depending on the work of Black physicians is tenuous considering the limited number of Black physicians. While Black physicians describe experiencing a sense of pride in their diversity work, they also acknowledge that this work demands a sacrifice in time that would otherwise be dedicated to personal wellness or career development. 

Black individuals have always been underrepresented in medicine in Canada. The obstacles start early and it’s hard not to appreciate the interplay between socioeconomic status and race. To make matters worse, many Black individuals don’t have examples of Black doctors in their lives. It's hard to imagine being what you don't see. Stark barriers to entry in medicine exist at every level. As students, one of the primary obstacles is a lack of mentorship. Getting through medical training is difficult as it is, but it's even harder when so few people who have endured similar challenges are available to provide advice and support. As Black physicians attempt to find ways to be their true selves in the workplace, race/ethnicity is thought to be a barrier to fulfilling mentoring relationships, reinforcing perceptions of isolation. While Black mentors are generally desired by Black physicians and residents, they are in short supply. 

A health care setting rife with micro-aggressions (ie, subtle slights and insults that serve to demean, marginalize, or otherize) generates a profound sense of personal and professional invalidation among minority physicians and residents. Black physicians and physicians in training regularly report encountering racially/ethnically motivated behaviours from numerous sources, including peers, co-residents, faculty members, attendings, program leadership, colleagues, ancillary staff, and patients. Such encounters fall on a spectrum ranging from nuanced interactions to glaring anti-Black racism. Predominantly, these encounters are subtle exchanges that send denigrating messages to Black residents. Toxic and oppressive work environments can instil a fear of retaliation for being vocal about racism and sexism. The lack of mentorship, promotion denial, and work environments embedded in anti-Black racism and sexism is sadly not uncommon amongst Black physicians.

Black medical students and residents face considerable challenges. Evaluations of Black trainees completed by faculty members frequently demonstrate racial bias compared to non-Black trainees. The medical school and resident selection process can play a significant factor in students’ future professional success, on occasions in which it is embedded with bias, severely disadvantaging Black students. The lack of Black faculty results in fewer potential mentors and role models for Black students and contributes to a leaky pipeline for Black trainees. Residency is a critical time during which trainees develop a professional identity, an understanding of how they fit into their work environment and generate plans for career development. This period is difficult for all residents, yet, the transition from medical resident to independent practitioner is a tenuous period for Black physicians secondary to race/ethnicity. These challenges include: 

• training experiences characterized by pervasive discrimination, lower expectations from supervisors, and harsher consequences for mistakes
• a schism between personal and work identity
• pressure to assimilate
• social isolation
• minimal professional mentorship

The ubiquitous experience of being part of a highly visible minority is difficult to explain to those who have not experienced it. Being "one of a few" Black physicians in almost any setting is exhausting. This visibility accentuates a sense of vulnerability at the hands of more senior physicians. Although the sense of vulnerability may decrease somewhat as experience is gained, awareness of visibility can still persist. Social isolation from non-Black peers and supervisors is frequently encountered by Black physicians and residents. While physicians and residents of all races require support, a support network is less available to Black physicians and residents. Many Black individuals in healthcare feel like outsiders in the social interactions with colleagues, supervisors and trainees. This can include specific moments of discomfort in social conversations, not being invited to outings with peers as well as a generalized discomfort with not being surrounded by people that look like them. Feelings of not having anything in common with their colleagues, which inhibits making small talk or sharing personal experiences despite the intense amount of time spent with their "team" is common. This results in a need to look outside of the work environment to find a social network to support challenges unique to their training experience.  Aspects of the identities of Black physicians are in conflict and occasionally, they have to make a difficult choice between personal identity and work identity. Either choice can be perceived as coming at a cost. Black physicians may even feel compelled to downplay, disguise, or transform their true identities to be accepted at work. These experiences often come with the implication that certain aspects of racial/ethnic identity lack professionalism. For Black physicians, this perception creates a duality between the piece of identity that they could display at work and their authentic selves. Challenges reconciling professional and personal identity and the often perceived pressure to conceal aspects of their racial/ethnic identity are associated with lower job satisfaction and higher turnover among targeted individuals. A lasting dissatisfaction with the social environment may occur. Lack of shared experience between non-Black and Black colleagues may lead to differences in responding to the group process and then to frustration and conflicts. 

Despite describing frequent experiences with bias, Black physicians often express reluctance to report events to supervisors and administrators. Multiple barriers prevent open discussions. A sense of hierarchical vulnerability preclude Black physicians from reporting instances of bias, particularly when perpetrators were faculty or in a more prominent position. Black physicians worry that speaking out would incite retribution. 

Other reasons for not reporting bias include beliefs that such efforts would be met with inaction, fear of being perceived as “playing the race/ethnicity card,” and difficulty expending time and mental energy. Occasionally, Black physicians are often expected or told to execute “diversity” efforts such as chairing diversity committees, mentoring Black trainees, and the like, and then are rarely recognized or compensated for this invaluable work. They are expected to perform the role of race/ethnicity ambassador at their institutions as they were called on to fix problems related to diversity, shoulder additional care for Black patients, and serve as experts on racial/ethnic issues. They are unfairly tasked with the complex and overwhelming chore of remedying the structural outcomes of centuries of institutionalized racism that they did not create in the first place. Often, they are the only individuals working on such initiatives. Despite being tasked with the responsibility to develop initiatives to enhance diversity and inclusion, they are allocated insufficient resources for programming to be successful.

For Black physicians, racial prejudice and anti-Black racism tends to manifest itself in the disrespect by coworkers and perceived difficulty in advancing professionally. Race/ethnicity has a substantial influence on underrepresented Black physicians because they are less likely to be promoted, obtain less National Institutes of Health funding, and receive lower compensation than their counterparts of white race/ethnicity.  Connections among majority physicians results in their white colleagues receiving guidance and support from each other to the exclusion of the minority members of the group. Research among medical students has demonstrated racial/ethnic disparities in the receipt of academic awards and in the use of positive language in letters of evaluation

As Black physicians navigate challenges to their identity, they develop multiple coping strategies. Some make a conscious choice to mentally separate their authentic identity from their work environment—which they often perceive to be threatening—and adopt a stance of hypervigilance. Black physicians also have an overwhelming pressure to be perfect to bring stability to personal identity and assert their belonging in the workplace. This behaviour leads to a heightened awareness about the perception of external factors, including speech patterns, body language, and clothing. In many cases, challenges of personal identity are exacerbated by limited social and professional support. Black physicians' high visibility and role as community representatives may have intensified pressure to perform while increasing isolation. Coping strategies may sometimes lead to a destruction of Black  physicians' mental health and overall wellbeing. 

If the Canadian medical profession cannot adequately support Black students/residents and promote Black physicians, then numbers will be affected. Black physicians are at a higher risk of withdrawing from residency than their counterparts of white race/ethnicity and are more likely to take extended leaves of absence. Unfavourable treatment on the basis of race/ethnicity has been associated with higher physician turnover and lower job satisfaction. Every Canadian Black physician that leaves the profession is a loss to the profession since they have a critical role in caring for Black patients, teaching and mentoring more Black trainees, and performing more critical research to eradicate health inequities. 

Not uncommonly, Black physicians and residents are subject to overtly anti-Black racist behaviours by patients—for example, when an individual or family specifically requests a white clinician or when patients voice xenophobic ideologies, even if it is not targeted toward the Black race specifically. The emotional harm experienced by the clinician should not be underestimated. When faced by an anti-Black  racist attack, an ethical conflict emerges for Black physicians between the duty to provide care and the duty not to treat patients against their wishes and to do no harm. Indeed, in certain situations, there are also legal requirements to provide care. Bias against physicians from patients are symptoms of the same disease — a reluctance in medicine to take a stand on issues of social justice and equality, and an idea that caring too much about equal treatment gets in the way of practicing the science of medicine.

We are increasingly realizing that anti-Black racist and sexist bias against patients is a pervasive issue. There are long-standing discrepancies in health care outcomes based in part on racial discrimination. These findings are not just historical facts but reflect contemporary conditions. Black patients are more likely to feel comfortable with Black doctors and more likely to adhere to certain preventive measures delivered by Black doctors, research shows. And Black doctors are more likely to practice in  communities that have a Black population.

This is especially important given that Black Canadians have greater barriers to health care than white Canadians, resulting in higher rates of chronic disease. More Black physicians in the system establishes trust in the system. An entirely white staff discourages Black people from using those facilities. There is also a stigma amongst the Black community against seeking mental health treatment and this can pose quite a challenge. Some Black patients figure it's not necessary, and that there are ways to get help other than talking to a stranger—like going to church or talking to family. There is also a misconception among both Black patients and non-Black doctors that Black Canadians are more resilient while continuing to confront institutional racism. But that assumption can decrease the likelihood that Black patients get diagnosed or treated.  Unconscious racial biases prevailing amongst non-Black health care professionals do a disservice to Black patients seeking any kind of health treatment, and being a Black physician can truly offer Black patients something more.