An assistant professor reflects on racism in the hospital workplace.

TRANSCRIPT

[MUSIC PLAYING] LIDIA SCHAPIRA: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Welcome to JCO's Cancer Stories-- the Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org.

MARJORY CHARLOT: Recently, I was caught off guard when my white elderly patient, lying in his hospital bed with his daughter and wife at his bedside, asked me to hold my hands up against his because Blacks have longer fingers. I am a medical oncologist and an attending physician, supervising a team of two medical interns, a medicine and a pharmacy resident and a medical student.

This incident occurred during our routine morning rounds on the inpatient oncology service. The silence in the patient's room was palpable. My emotions in that moment spun in all directions from the shock of this patient's unexpected derogatory and racially charged statement. I was angry, upset, humiliated, and embarrassed all at the same time.

The stereotypical and discriminatory generalization that Blacks have longer fingers and his request for me to hold my hands up to his was demeaning. His focus on my skin color and physical features, as opposed to my medical knowledge and expertise, was revolting and an insult to my identity as a physician. To get on with the task at hand of reviewing the patient's overall status, I decided to ignore his comment, gently held his hand, and addressed the remaining questions his family had regarding his condition and hospital course.

As I walked out of the room, I felt compelled to immediately debrief with my team, but I soon realized that I had no idea on how I was going to do this. Some might have advised me to brush off this experience and pretend it didn't occur. Others might have pointed out that this patient was elderly, likely had hospital-associated delirium, and may be unaware of the meaning behind his comments.

In the moment, however, I felt two things to be true. First, this was an explicit example of interpersonal racism during a patient-physician interaction. Second, despite the patient's action, I needed to uphold the oath I took almost 15 years ago to provide my patient with the best care possible while forgoing the personal attack on the essence of who I am as an individual and physician.

The collision of my identity as a Black woman, physician of color, academic physician leading a team of trainees, and a doctor who feels an obligation to provide good care to every patient, regardless of the circumstances, contributed to how conflicted and uncertain I felt in the immediate moment. The culmination of my four years of medical school, three years of internal medicine residency, three years of hematology-oncology fellowship, and nine years as a staff medical oncologist did not protect me from being viewed through a racial lens.

I knew that I could not go on about business as usual and was unsure how best to respond in that moment. I quickly said to the team that what the patient said was inappropriate and racist. Following this, my intern sincerely apologized. I told her there was no need for her to apologize because she was not at fault, and sadly enough, this was the extent of my debriefing.

My husband, who is white and a fellow physician, was mortified when I discussed the incident with him that evening. As I was processing this incident during our conversation and then sharing this experience via a group text message with a close network of friends from residency, who for the most part identify as female physicians of color, I came to the realization that I needed to debrief further with my team. I cannot not let this teachable moment pass without the recognition it clearly deserved.

Explicit discrimination in the workplace from patients is not uncommon for physicians of color, physicians with an accent, physicians who wear traditional clothing or head covering, or physicians with a name that is unfamiliar or perceived as difficult to pronounce. The collision of the multiple identities that I embody as a Black female academic physician is likely experienced by others underrepresented in medicine.

In the midst of this encounter with my patient and as an academic, I wondered if there were best practices to guide a response to interpersonal racism during a medical encounter. I also wondered what protections are in place within the hospital for physicians experiencing racism from their patients. I learned that our hospital does have a policy on nondiscrimination against providers and staff, that these violations should be reported to the attending physician or nurse leadership, and that it is the attending physician's or nurse leadership team's responsibility to discuss this issue with the patient. There are also resources and a script available online to guide discussions when a patient requests to change providers on the basis of the patient's discriminatory views.

However, as an attending physician experiencing racial discrimination from a patient who is not requesting a change in provider, I felt the immediate responsibility to address this but did not have much guidance. The morning following this incident, instead of the planned teaching on the management of malignancy-associated hypercalcemia, I opted to discuss racial discrimination against medical providers. Without access to evidence-based guidance at my fingertips for the questions I was contemplating, I used what I experienced to generate this discussion.

Unlike my usual didactic lessons that are well prepared in advance, engaging, and presented with confidence, I approached this discussion with my raw emotion and feared that my words would fumble. I also feared that my trainees would be uninterested or uncomfortable with openly discussing race and racism. However, I was pleasantly surprised by my trainees' reaction and their level of comfort in engaging in this discussion. A few of my trainees shared their personal experience witnessing racism outside the workplace while others attentively listened and were perhaps not ready to share their thoughts or feelings in that moment.

Leading this discussion was a moment of vulnerability, but it was also empowering to accept the discomfort in creating this necessary dialogue. After our team discussion, my intern explained that her apology after the incident was because she felt sorry I had to go through this experience and that she was not apologizing for the patient. I was encouraged by her acknowledgment and her apology, which left me with a sense of optimism about the next generation of physicians and their willingness to recognize inappropriate and unjust interactions during the medical encounter experienced by physicians underrepresented in medicine.

But is this enough? As I reflect on how my team of trainees, from their position of privilege, could have further responded as an ally, I recognize the need to provide trainees and colleagues with communication tools and skills to feel empowered to respond against discrimination during medical encounters. Calling out the inappropriate behavior, generating a response aligned with human decency and fairness, and creating opportunities for open discussions with trainees can be a start in addressing the gap in best practices in guidelines on confronting discrimination as physicians in the hospital workplace.

As an attending physician, I acknowledge that I am in a position of power, and most often, patients are in a vulnerable state and at the mercy of their providers. In this particular encounter with my patient, I don't believe directly addressing his discriminatory comment with him would have made a difference in his care or his outcome.

Dismissing this encounter altogether could, however, have had a lasting impression and influence on how my team of trainees approached discrimination during other medical encounters. Trainees of color, as well as white trainees, need teaching on how to debrief and diffuse similar incidents. Our collective responsibility as physician leaders is not only to supervise and educate our trainees about the art and science of medicine as it pertains to managing medical conditions but is also to model humility and to teach them how to recognize bias and discrimination, feel safe to openly discuss discrimination of any kind, and most importantly, to teach them how to nurture and support their peers and colleagues facing discrimination.

Even when we are not comfortable and without formal training in dealing with patient-directed racial discrimination during the medical encounter, it is important for us as physicians to have these meaningful conversations outside of our comfort zone with our colleagues and our trainees. Admitting vulnerability as a seasoned physician is difficult, but we should feel compelled to lead these conversations to cultivate a medical community that stands together against all social injustices.

In retrospect, I am confident that this experience will continue to have a lasting impact on my trainees, and it served as my initiation to the professional responsibility I feel to create dialogue with my colleagues and trainees. I am optimistic that sharing this experience will empower other trainees to advocate for diversity, equity, and inclusively as they, too, become leaders in the hospital workplace.

In holding my patient's hands as a sign of my commitment to providing him with the best care possible, I felt empowered. Similarly, I will also hold the hands of my trainees, committing to lead them during these racially charged and divisive times, so that we can stand together against racism and injustices of all kind.

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LIDIA SCHAPIRA: Cancer Stories-- the Art of Oncology. With me today is Dr. Marjory Charlot, who is an assistant professor at UNC in the Department of Medicine and the Division of Oncology. Welcome, Marjory, to our program.

MARJORY CHARLOT: Thank you. Thank you very much for inviting me.

LIDIA SCHAPIRA: It's a pleasure to have you, and thank you so much for submitting and for writing this essay about such a difficult topic. The first question I have for you is this. Was it hard to write the essay?

MARJORY CHARLOT: It was quite difficult for me. I remember after the episode happening, just kind of when I got home, I was like, let me just jot down what I'm feeling in the moment. And I just sort of just threw some words onto paper.

And it's actually interesting for me because it's not a process that I've ever gone through in terms of experiencing something either in the clinic or in the hospital and then feeling this need to go ahead and write. But what I wanted to do-- and this was certainly not the actual essay, but it was just a way for me to express what I was experiencing, pen and paper and just kind of leaving it there and having that space to kind of have this conversation with my husband and close friends, was pretty much the process that I went through.

And then really, I didn't go back to that experience for several months, and so then I went back and said, oh, these are the things that I was experiencing at the time. And so it was interesting.

I think with sort of the resurgence of everything that's been going on in the country around the injustices among the Black population in particular, I think that really drove me to sort of go back to this essay and to really think about the things that I experienced and figure out a way-- how do I share this information not only with the trainees who are involved with this particular episode but really with everyone, colleagues, people in oncology? Just because I just felt the need to give back and really felt the need-- how do we respond as a profession? And so that was kind of my process in terms of writing this.

LIDIA SCHAPIRA: So that's fascinating, so writing both as a means to process a difficult experience, taking the time to really let the experience sift through all the levels, and then crafting a beautiful essay that also serves as a message and a call to action in many ways for your colleagues. Let me ask you another question that came up as I was reading it. You talk about the collision of multiple identities that you embody as a Black female physician, and I wondered if you could unpack that sentence a little bit for me and perhaps for other listeners of the podcast and readers. How did you come about thinking about all of these multiple threads that together define your identity? And how do you think about this?

MARJORY CHARLOT: Sure, sure, so in terms of thinking about who I am on a day-to-day basis, the first and foremost, I think, when people see me or meet me, it's pretty apparent that I'm a Black woman. And so that's one part of my identity that for lack of a better word is quite obvious. You see me in person.

And I think that plus my identity as a physician, as a teacher-- and it's quite interesting because I think about these things particularly when I am interacting with patients. When I have a patient that happens to be Black, I think that there is this sense of familiarity, a level of comfort that I-- and this is just from years of experience that I've just noticed, that when I walk into the room, it's sort of that unexpected or this recognition like, well, we've got something in common, even though it may just be on the basis of gender.

Or it may be on the basis of race and gender. So I think that that piece of it is very central in terms of how I interface and interact with my patients, and so that's part of that multiple-identity piece that I write about in this essay.

I think there's also this part of being a physician as well as being an oncologist. I think that there's something very different in terms of being a provider that specialized in one particular area, and so I think that also speaks to who I am.

And then I think lastly for me, being an academic, so being in an environment where the expectation is not only to care for patients but also to be a teacher and a role model-- and so it was thinking about all of these different roles that I play in any particular interaction with patients or in the work environment sort of plays into this multiple identity issue that I briefly discussed in the essay.

LIDIA SCHAPIRA: So let's talk a little bit about that. The number I hold in my head-- and please correct me if I'm wrong-- is that perhaps 1% of all oncologists or less or fewer are Black women.

And the other piece about this is all of the isms that we can attach, the sexism, the racism, all the other isms that really provide such a hurdle for us or are such a hurdle in thinking about how we can be our best selves and perform at our best as academics as oncologists. I wonder if you can reflect a little bit on that. How did all of these different aspects that shape your identity guide your decision to stay in academia, and how do you think that your identity influences the kind of academic that you are and aspire to be?

MARJORY CHARLOT: That's a great question, and so, I mean, I'll tell you a little bit about me. So I grew up in Boston in a neighborhood that was predominantly Black. I'm a first-generation American. My parents originally came from Haiti.

And so what influenced me, first of all, to even become a doctor was having a Haitian pediatrician, who at that time actually did house calls. And so this pediatrician was so integral to the community. He was a community member, and so that really influenced the type of physician I wanted to be. I wanted to be someone that could relate to the community of patients that I was taking care of.

And then having gone through all of the medical school and training that I've been through, it wasn't until, I would say, during my residency in Boston-- I did residency in the hospital that I was born in, and so I could relate with my patients from saying, oh, I know that street, or I know this restaurant or this shop or this organizer in this particular community. And so for me, that connection really influenced my decision to stay in academics because having gone for residency and fellowship, connecting with students, connecting with mentors, I felt like that was a community in and of itself.

And so for me, I wanted the opportunity to really influence trainees, trainees that look like me, trainees that don't look like me, trainees who want to learn about oncology, learn about community, learn about underserved patients, because that's who I feel I represent in terms of the environment that I grew up in. And so that really influenced my decision to stay in academics, because I wanted to be a part of really having an influence on the next generation of trainees to ensure that all voices really are represented in this field. And so that, for me, as a Black woman from an urban area that was not necessarily affluent-- but I wanted to be able to speak to that experience and to be a voice for other students coming up who live that experience.

LIDIA SCHAPIRA: Let's talk about where you are now. In the essay, "power" and "empowered" appears multiple times. As an assistant professor and team leader, you are now both in charge and confronted with this episode of racism.

What do you do? You read the protocol for the hospital, and it basically says, you are the person with the most power. How did that feel for you, and what did you do with that power?

MARJORY CHARLOT: That's a great question as well. I think initially, when I was trying to figure out, OK, well, what do you do when this happens to you? Just because I wasn't clear exactly, what is the responsibility that I have as a provider, as this patient's attending of record in terms of going through this experience?

And so at the time, I can tell you, it was not a powerful moment during this interpersonal racism event. But it wasn't until after in terms of walking out of the room and knowing that I needed to address this and I needed to figure out, what exactly do I come away with with this experience? And what exactly do my trainees, who are in the room, come away with this experience?

And I acknowledge the fact, yes, I am the attending of record. I lead the team, that I am in a position of power, and this patient is a patient. And like most patients, I think it is a vulnerable moment to be in the hospital. And so understanding the power dynamics as a physician and a patient-- I think that was one of the thoughts that came into my mind initially and then also this feeling of, I need to do something about this. I can't let this go.

I also stressed the importance of being an academic physician. My role, I feel, on the wards is primarily to teach. I feel like the interns, the residents, the pharmacy medical students, the students are there to learn.

The interns-- they're the doctor. They're doctoring. They're providing care, and my role is really to advise, supervise, and to teach. And so I felt that given that I have the luxury in academics to not only care for patients but to also teach my trainees, I felt like that was the power that I was really focusing on and really trying to harness as I went through this experience and wanted to really guide my team at the time.

LIDIA SCHAPIRA: Let's talk a little about that. You say very specifically in your essay, which is part of the message, that you realized that it was a teachable moment and that part of the role of an academic physician is to teach communication skills so that other members of the team could respond to situations like the one you describe here. I love that thought, that by giving these skills and tools, the team could respond to the situation if another situation like this was enacted. Tell us a little about what those communication skills are and how others should be teaching those to their students and mentees.

MARJORY CHARLOT: Right, and so I think with regards to the communication skills, one of the first things that I thought was important was really to give the trainees the space to speak because I feel oftentimes-- and this is in my experience, talking about race and racism while on the wards. That's not something that you just generally do. It's not really part of the curriculum. It's not part of the evaluation form, so it's not something that organically happens.

And so for me, I thought that having that space for my trainees to really just discuss what just happened, what were their thoughts, how are they feeling, and really getting a pulse to what is kind of already happening either within their training programs-- since I have a team of both pharmacy and medical students as well as internal medicine residents on the ward, it was really an opportunity for me to get a better understanding on what exactly do they talk about in their training. Do they even discuss race and racism during their training? So I thought that that was the initial piece of this communication skill, that that's necessary, is really just being able to listen.

So I think a lot of times, we think about, oh, we need to teach people this is what you say. Here's the script that you use. But I think really offering that space is part of that communication. That space to talk, that space to listen, I think, is number one.

Number two, I think, also stressing the importance that it's not so much my role, either as a physician leader or either as the person who's confronting this issue of racism or really any of the isms-- it's not my specific role to necessarily respond especially in the moment where a lot of this is very fresh, and you can be very stunned and shocked. And it's really difficult to even talk or to speak, to say anything.

And so thinking about those around us and what their roles are as allies-- and reason why I bring this up is because I think that perhaps-- and I can't make this assumption because probably for some allies, as I could see, at least in the room when I went through this experience, that it was just complete silence. So I felt that maybe everyone else in the room was also experiencing this shock and felt stunned and didn't really know what to say, and I think that that's OK.

But I think what's not OK is to just completely ignore it. And so with communication skills, I think it's really important to-- even if this is not an area that the individual may feel comfortable in discussing, that it's important to just say, OK, let's take a step back. What just happened in the room was not OK.

And for me, that was a process that I went through where I was like, OK, it's not OK. It's ignorant. It's racist, and it's not right, and kind of left it at that.

But I think going back, whatever that time and space may be, going back and saying, OK, team, what just happened was not OK. What were your thoughts? What were you feeling? How do we as a team process this?

And again, I don't really have the necessary answers in terms of the best ways to do that, but I do know that listening, calling these inappropriate actions out, and having that discussion-- I think that's the beginning of developing these skills on how best we can communicate with each other as a team. And then I think the other piece-- if appropriate, going back and communicating that with the patient as well. I don't really get into that that much in this paper, this essay, but I think that's certainly a skill when it's appropriate. And I think that there may be different nuances within all of these interactions where the appropriateness of going back to a patient really is going to be determined, I think, by the individual or the team members that are affected by it.

LIDIA SCHAPIRA: It's worth repeating that communication skills training is often about accepting and understanding the emotional load of the work. In this particular case, as you say, a lot of it has to do with being confronted with what is unjust. Listeners will perhaps have other associations and memories of a time when they have been faced with this, and to add to the challenge you describe here is that you are the top doctor for this patient, making it an almost unbearable situation.

I thank you for describing this to the readers to help us all feel your anguish and identify opportunities to respond in such a situation. Your essay provides a very important contribution to our professional literature.

So my last question is this. I'm sure you've thought about it, and you hint at this at the essay. But if there is a next time-- and there probably will be-- can you imagine how you will react?

MARJORY CHARLOT: Right, that's a very interesting question in that it's so hard to predict only because-- and the reason why I say this, too, it's only because these moments-- they catch you by surprise. And then there are times where you're not necessarily surprised in terms of my experience, again, as a Black female physician in that there are times where I come in, and I'm like, oh, I know what I'm walking into. I'm guarded.

With what I described in the essay, it was shocking to me just because this was a patient that I had an established relationship with throughout the hospitalization, and that comment just came out of left field. It wasn't an initial interaction with the patient. But I feel that if that's the first thing that's coming at me when I first meet a patient, I feel that that's a lot more comfortable to address head on.

But I think if you already have this established relationship and then all of a sudden, you hear this type of comment, I think it makes it quite difficult. So it depends on what that next time is like in terms of where I am in that day. How many microaggressions have I gone through that day? So I think all of those pieces really influence my response.

And so it's really difficult to say exactly-- OK, I wrote this essay. I've processed. Now I know I'm prepared for the next time. I wish it were that simple, but unfortunately, it all depends on what's happened that day, that week, that month, where we are in the country with regards to different social injustices. So unfortunately, it's one of those things that I can't predict how I would respond.

LIDIA SCHAPIRA: It's refreshing to hear you say that. Of course, it's impossible to know. Thank you for sharing and taking the time to write about it and sending it, so our thoughtful community of oncologists can think about how they can also be allies in addressing racism in the clinic, in the office, or in the hospital.

MARJORY CHARLOT: Thank you so much, Dr. Schapira. It's really a pleasure to have this opportunity to share my story and to lift my voice in this area. So thank you again, and thank you to the Journal for accepting this essay.

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LIDIA SCHAPIRA: Until next time, thank you for listening to this JCO's Cancer Stories-- The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you are there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories-- The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all of the shows at podcast.asco.org.

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