“Is it because I’m Black?”
These words haunt me. They came from the voice of a Black man lying down on an emergency room bed, in pain.
I was in the middle of an emergency medicine shift—an infamous rotation of my internal medicine residency—where we are pushed out of our cognitive comfort zone into a chaotic, fast-paced environment full of all kinds of smells, sights, and sounds. I was not prepared, however, to hear that patient’s question.
After collecting the patient’s history and performing a physical exam, I returned to the main workstation where my attending was sitting. I presented to him and began to order medications, labs, and other diagnostic tests to evaluate this patient, who had come to the emergency room with abdominal pain. The patient’s nurse then approached us, stating that my patient was asking for pain medication. I already had placed the order in the system, but my attending quickly said to me, “Don’t give him any oxycodone—I think he’s asking for too much. Acetaminophen is fine.”
I felt uneasy and unsure of what to do. I tried to reason with the attending that this patient’s degree of pain deserved a strong medication—at least in the immediate time while in the emergency room. It seemed very reasonable to provide meaningful relief to this gentleman’s pain; he is a human who was suffering, and I had planned to treat the pain acutely while investigating its etiology. Training in a background of an opioid epidemic, I developed a clear practice of when I would consider prescribing opioid medications. In this situation, I felt very comfortable treating my patient’s acute pain with an opioid while in the emergency room. Even so, my attending stood firm with his decision. Reflecting on how the opioid epidemic disproportionately impacts Black patients, I was acutely aware of the assumptions my attending may have been making by refusing to provide my patient with opioid pain relief. Despite my reasoning and reflections, I felt uneasy in voicing these strongly and unsure of countering my attending’s decision—I was caught in a web of medical hierarchy and professionalism that called for me to respect my superior.
Drenched in the sweat of moral tension, I sat in front of the computer, my mouse pointed on the “discontinue” medication button, as my attending walked away. Slowly walking back to the patient’s room, I told him that we could offer him some acetaminophen, but we were unable to give him stronger pain medication. He patiently asked why, and I fumbled with my answer, muttering something of an apology for not being able to fulfill his request. He paused for a few seconds, as I stood there feeling helpless, and then calmly asked me the question that put a spotlight on systemic racism in the emergency room that day: “Is it because I’m Black?”
It is well known that Black patients’ pain is undertreated and that this is linked to systemic racism.1 Medicine at all levels is steeped in racial bias—from medical school and beyond—causing erroneous, ridiculous, myths such as Black people having less sensitive nerve endings or thicker skin. Myths around pain, in particular, lead to poorer quality of care and poorer health outcomes in our Black patients—an unacceptable fate that presented itself in the emergency room that day.
My patient’s voice echoed through my ears. I suddenly felt a tightness in my throat, swallowed, and responded with a sigh of something between frustration and embarrassment, “No, of course not…” As I said this, I felt my hand point to my own brown skin, perhaps to say, “How could it be? I’m with you.” But, the person-of-color-activist in me felt defeated; how could I let this happen? Training in a location that was predominantly white, I often sensed a mutual belonging when caring for patients of color. In fact, patients had routinely disclosed to me mental health effects of racism, and I always felt that there was some sort of unspoken shared understanding of what it meant to be a person of color living in America. However, in this situation, the kinship I often felt with patients of color suddenly felt challenged.
This kinship started decades ago, when Black civil rights activists fought for the Immigration and Nationality Act of 1965.2 Prior to this act, national-origin quotas favored those from Europe, but this policy change allowed immigration of people from non-European countries, including India. In other words, the direct work of Black American activists quite literally allowed for my brown skin to exist in this country. Not only that, I grew up learning about the shared non-violent philosophies of Martin Luther King and Mohandas K Gandhi. I owe my American citizenship to the Black Americans that fought for my parents’ ability to immigrate here.
Despite this kinship around color in America, when I found myself pointing to my brown skin in front on this patient, I very mistakenly conflated my “brownness” with my patient’s “blackness.” The oppression, mistreatment, and genocide of Black people in America is based on an entirely different history than my experience as a woman of color. As we learn about racial disparities, Black patients are consistently shown to have poorer health outcomes and increased mortality, and these outcomes are rooted in an anti-Black racist legacy in medicine. Perhaps it is this conflation that made me blind to my own perpetuating of systemic racism—and why I was not able to stand up for my patient that day.
Experiencing moral tension around being told to withhold pain medication from my Black patient, I hid under broken ideas of medical professionalism and hierarchy, prioritizing these false values over standing up to racial injustice. Yet, the pain of my moral tension is never greater than the untreated pain of Black patients. In an ideal world, I would have asked this question before my patient, first asking myself and the healthcare system I operate within, “Is it because he is Black?” before making clinical care decisions. Had I asked my attending this question, I might have evoked a necessary civil disobedience of sorts in medicine. I can envision an alternate scenario where after my attending denied my patient opioid pain medication, I asked him “Is it because he is Black?” to start a critical dialogue on addressing racism in medicine. In doing so, I would have challenged medical hierarchy as an upstander of racial justice, with the hopes of starting more conversations around anti-racism.
It is easy to blame the attending that day, but I acknowledge and appreciate the power I hold to advocate for my patients. It is time that we pause and not only check our biases at the door, but care for Black patients in ways that heal the wounds of racism in medicine. Racial justice should be a mandatory part of every medical school curriculum. My patient taught me that racially just medical education demands at least three things: (1) breaking down hierarchy in the name of racial equity; (2) training that fuels practical, patient-centered actions to disrupt racism; and (3) infusing anti-racism tenets into medical professionalism. This could ignite a revolution to reverse the history of racial oppression in medicine—all in the name of our first obligation: do no harm.
(Support: Megha Shankar is supported by a VA Office of Academic Affairs Advanced Fellowship in Health Services Research. The views expressed herein are those of the authors and do not reflect the views of the Department of Veterans Affairs.)