Begum F, Dodson B, Srinivasan A. The “who” and the “how” when working with tribal communities. Harvard Public Health Review. 2021; 30. 

Introduction

COVID-19 has disproportionately impacted Black, Brown and Indigenous communities, but vaccine roll-outs have been slowed in these communities due to the long-standing problem of inadequate public health infrastructures, health care deserts, and the history of racism in medicine that has generated a justified distrust of COVID-19 vaccines (Curtice & Choo, 2020; Nephew, 2021; Khazanchi et al., 2020).

To mitigate this distrust, underrepresented minority physicians, URMs, have had to take the lead on hosting virtual community forums, outreach programs and many more public-facing “I trust the vaccine” type campaigns to engage their communities in conversations about the vaccines, and assure them that the vaccines are safe and effective. For example, many Black, Indigenous and Brown health care workers have publicly advertised their receipt of the vaccine and their “why” for taking it (Siegler, 2021).

Such efforts have led to increased conversations about the vaccine, increases in vaccine uptake among Black, Brown and Indigenous communities, and general awareness of the importance of URM physicians’ voices (Matt McLernon, 2021; Radnofsky et al., 2021; Shakya & Yang, 2020). However, missing from the conversation about the overarching impact of this pandemic is the unfair burden that has been placed on URM physicians, including URM medical school faculty, and the potential impact on burnout and attrition that may result from this exploitation.

The unique experience of URM physicians during COVID compounded with ever-present structural racism in medicine indicates an urgent need to redesign the methodologies that have been used to assess the individualized experience of burnout to measure the impact of institutional exploitation on URM medical faculty.

URM Physician Burnout

According to Garcia and colleagues’ 2020 study, URM physicians are less likely to report burnout compared to their non-Hispanic white counterparts (Garcia et al., 2020). However, Cantor and Mouzon question Garcia and colleagues’ conclusion by critiquing the methods that were used to measure the level of burnout and suggest that other factors may be at play (Cantor & Mouzon, 2020).

Cantor and Mouzon propose that controlling for specialty in Garcia and colleagues’ multivariate model may mask URM physician burnout, as studies show that primary care physicians experience more burnout than other specialists, and URM physicians are more likely to work in primary care (Cantor & Mouzon, 2020). Additionally, Cantor and Mouzon suggest that because URM physicians are more likely to work with underserved populations, they may have different expectations about their workload, leading to differences in reported burnout.

Cantor and Mouzon call for modeling approaches like nesting and stratification, complemented by in-depth qualitative research methods, to disentangle and interpret complex associations between race and ethnicity and physician burnout. Similar research approaches are needed to understand and intervene to reduce burnout specifically among physician faculty in academic medicine, who are routinely tasked with the role of diversity ambassadors while enduring discrimination and punishment for speaking out against systemic racism in their medical institutions.

One prominent example of this occurred in August 2020, when Dr. Aysha Khoury, an instructor at Kaiser Permanente Bernard J. Tyson School of Medicine, was suspended just hours after she had a conversation about racial biases and health care disparities with eight students (Asare, 2021), despite being asked to do this work and even being praised for it in the past. The school publicly denied that Dr. Khoury was removed for discussing anti-racism-related content with her class, but has not yet given a clear answer as to why she was suspended.

Similarly, In February 2021, Dr. Princess Dennar, the first and only black Med-Peds residency Program Director at Tulane Medical School, was suspended from her role months after suing Tulane for racial and gender discrimination (Mayer, 2021). When she was hired in 2008, the dean of the medical school, Dr. Lee Hamm, told her that he “didn’t want to change the face of Tulane” and that he was afraid “white medical students wouldn’t follow or rank favorably a program with a Black program director.”

These are just two examples of what many URM physicians in academic medicine often encounter, as at the beginning of many URM physicians’ careers, their medical institutions welcome them as a novelty. However, by mid-career, there seems to be a stagnation and some institutions don’t give them space to openly speak out and critique discriminatory practices, and in fact many who do speak up, face repercussions of not being advanced to prominent leadership positions.

In addition to being silenced by their institutions, dealing with both individual and systemic racism, and working in under-resourced facilities, URM physicians are also taxed by institutions like the Journal of American Medical Association (JAMA) exploiting their work on systemic racism while simultaneously delegitimizing the use of the term racism in medicine. In a podcast JAMA released on February 23rd, 2021 titled “Structural Racism for Doctors – What Is It?”, Dr. Edward Livingston states that “the word racism might be hurting us…I grew up kind of being anti-racist, yet I feel like I’m being told I’m racist because of this modern thing in America around structural racism, but what you’re talking about isn’t so much racism, as much as that it’s more of a socioeconomic phenomenon” (JAMA, 2021).

An accumulation of such repeated instances of being discounted in medicine, along with the COVID-19 pandemic, produces a specific type of burnout for many URM physicians in academic medicine. Not only is it physically taxing and exhausting work, but dealing with frustration and anger in response to repeated racial incidents can also take a toll on one’s mental health. As Garcia and colleagues noted, surveys may underestimate burnout of URM physicians due to their greater discomfort disclosing burnout symptoms compared to white physicians. Further, with such relatively few URM faculty, it is very difficult to sufficiently mask individual survey data, so that URMs may feel unable to safely disclose their true responses. It is therefore crucial to reveal the true extent of burnout among URM physicians and act now to dismantle discriminatory practices that clearly harm URM faculty in academic medicine.

Where Do We Go from Here?

Studies showing lower self-reported burnout among URM physicians co-exist with evidence that URM physician faculty endure more social isolation, discrimination, and burden of nonclinical responsibilities associated with diversity efforts (Garcia et al., 2020; Lawrence, 2021). Disentangling the mechanisms that produce these seemingly inconsistent results, as Cantor and Mouzon suggest, can ground interventions to improve URM physician satisfaction and retention. Yet there are immediate steps that medical schools can take to address underlying structural racism that interferes with career advancement of URM medical school faculty. The need, desire, and expectation of them to be ambassadors of diversity, equity and inclusion (DEI) efforts along with champions of health equity result in excessive time engaged in service activities, which are undervalued, undercompensated and often not considered in academic promotion and tenure decisions (Acholonu & Oyeku, 2020). Many physicians admit that their work outside of academic medical research has skyrocketed since the beginning of the pandemic, with increased community outreach and advocacy for health equity.

For this cycle to end, medical institutions must recognize the importance of all individuals contributing to DEI and health equity work. However, pushing these efforts through conversation realistically won’t get us very far. A proper reward and recognition system for service activity in the promotion and tenure process is needed (Schwartz, 2019; Joseph, 2021). With this in place, the DEI and health equity work already being done would help keep URM physicians on pace with their counterparts in advancing their careers, pushing all physicians to get involved, more evenly distributing the essential DEI and health equity work that every physician should do. There is still a lot of work to be done to reach true inclusive practices, allyship and health equity. Prioritizing the health of URM physicians is a great first step that can elicit benefits to patients from disadvantaged populations.

For many URM physicians, doing this work is their way of ensuring that their communities are cared for. If URM physicians didn’t step up to do this work, then Black, Indigenous and Brown communities would continue to be ignored, sidelined and left behind. URM physicians take pride in their work and see it as a privilege to be able to help their communities. However, to expect URM physicians to be the sole carriers of this burden is not only a fundamental failure of our public health system but an exploitation of their value.

This pandemic has revealed many forms of systemic racism, and one clear example in medicine is the failure to value and amplify the work of URM physicians. This abject devaluation and exploitation drives not just burnout and retirement, but early departure from academia and the health care workforce (Blackstock, 2020). Although we have been unable to find published data on the extent to which the COVID-19 pandemic has influenced URM physicians to leave medicine or consider doing so, the magnitude of this problem is suggested by published survey data showing that 6% of physicians are considering quitting medicine in favor of a new career, 8% want to leave patient care and 9% are planning to retire due to the pandemic (Murphy, 2020). Thus, studies to ascertain analogous information pertaining to URM physicians are warranted.

We cannot afford a mass exit of URM physicians, indeed there are only 5% of Black, 5.8% Latinx, and 0.3% Indigenous physicians in this country, a sharp contrast to our evolving US demography (AAMC, 2019).  This would be a loss that will not only exacerbate already existing health disparities, but that will also leave us wholly unprepared to fight the next pandemic.

References 

Arrazola, J. (2020). COVID-19 mortality among American Indian and Alaska Native persons—14 States, January–June 2020. Morbidity and Mortality Weekly Report (MMWR), 69. https://doi.org/10.15585/mmwr.mm6949a3

CDC. (2020, February 11). Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/communication/public-service-announcements.html

Daley, M., & Dietz, L. (2021). Navajo nation covid-19 occupational therapy care. Occupational Therapy Practice, 26(1) 13-15.

Doshi, S., Jordan, A., Kelly, K., & Solomon, D. (2020). The COVID-19 Response in Indian Country. Center for American Progress. https://www.americanprogress.org/issues/green/reports/2020/06/18/486480/covid-19-response-indian-country/

Israel, B., Eng, E., Schulz, A., & Parker, E. (2005). Methods for Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass; 2005

John Hopkins Center for American Indian Health. (2020). COVID-19 resources for Native American communities. https://resources.caih.jhu.edu/

Koh, H. K. (2015). Educating future public health leaders. American Journal of Public Health; Washington, 105(S1), S11–S13.

Marmot, M., & Allen, J. J. (2014). Social determinants of health equity. American Journal of Public Health, 104(Suppl 4), S517–S519. https://doi.org/10.2105/AJPH.2014.302200

Mello, M. M., & Wolf, L. E. (2010). The Havasupai Indian tribe case—Lessons for research involving stored biologic samples. New England Journal of Medicine, 363(3), 204–207. https://doi.org/10.1056/NEJMp1005203

National Congress of American Indians. (2017). A place we call home. What is the future of tribal housing? (pp. 26–32). http://www.cdc.gov/mmwr/volumes/66/wr/mm6601e1.htm

Peretz, P., Islam, N., & Matiz, L. (2020). Community health workers and covid-19—Addressing social determinants of health in times of crisis and beyond. New England Journal of Medicine, 383(1008). https://www.nejm.org/doi/full/10.1056/NEJMp2022641

Rosenthal, E. L., Menking, P., & Begay, M.-G. (2020). Fighting the COVID-19 merciless monster: Lives on the line—Community health representatives’ roles in the pandemic battle on the Navajo Nation. Journal of Ambulatory Care Management, 43(4), 301–305. https://doi.org/10.1097/JAC.0000000000000354

Subscribe to Our Newsletter

HPHR

© 2021 HARVARD PUBLIC HEALTH REVIEW: A PEER-REVIEWED JOURNAL
PRIVACY POLICY