I recently visited Montgomery, Alabama, a city that is no stranger to historical moments, and walked through the new National Memorial for Peace and Justice created by the Equal Justice Initiative to honor lynching victims. I also visited the accompanying Legacy Museum, which documents human-rights abuses of black Americans from slavery to the present. The metal columns that record victims’ names and the county where each lynching occurred reminded me of the many memorials that our country has built to honor its dead, including the Vietnam memorial in Washington, DC, and the World Trade Center memorial in my hometown of New York. There was a solemn sense of honor that reverberated throughout the space. It’s a tangible way of stressing that Black Lives do Matter and we can honor them, just as we honor any of our compatriots who have fallen unexpectedly and unjustly.
Visiting this memorial was important to me as a physician. History can dramatically influence how doctors practice medicine—including in the examining room—in at least two important ways. First, doctors are not immune to implicit bias, which is the unconscious, unintentional racial stereotyping produced by hundreds of years of racism that is part of our nation’s history. Such bias is widespread and has been shown to adversely affect the care we provide. For example, implicit bias leads to subtle differences in patient-doctor communication that result in poorer collaboration. Being unable to experience a collaborative relationship with physicians may make it more difficult for patients to comply with long-term management of chronic diseases such as high blood pressure and diabetes.
Second, African American patients enter healthcare institutions carrying the knowledge that social institutions have failed them time and again throughout our nation’s history. An empathetic understanding of this perspective can help physicians work to earn back the trust that is essential to the physician-patient relationship. Without this understanding, physicians may be quick to label mistrustful patients noncompliant or difficult, fueling more distrust.
Lessons Learned Early
Knowing our collective history can help physicians communicate more openly and honestly with their patients. Black patients report decreased levels of partnership with physicians, and are less likely to feel that their doctors understand and respect their values and beliefs. Conversely, when patients feel heard and understood by their physicians, they are more likely to participate actively in their own care. Cultural competency on the part of physicians includes taking an interest in the historical and present-day circumstances that affect their patients’ daily lives.
It’s likely better to start dealing with these issues and biases early. At the museum, I noticed that my seven-year-old son, Desmond, was one of the very few children present. Before our pilgrimage I had questioned my choice, as a parent, to bring him. But I thought back to the many ways in which this deeply painful and troubling history was minimized when I was a child and I was not allowed to see the truth represented by these brutal events. The thought that “it was such a long time ago, for short period of time” is refuted by the metal columns that proffered dates well into the mid-20th century, lined up as far as the eye could see.
The reasons given for these killings were stark and horrifying. “Arthur St. Clair, a minister, was lynched in Hernando County, Florida, in 1877, for performing the wedding of a black man and a white woman.” “Jack Turner was lynched in Butler, Alabama, in 1882, for organizing black voters in Choctaw County.” “After Calvin Mike voted in Calhoun County, Georgia, in 1884, a white mob attacked and burned his home, lynching his elderly mother and his two young daughters, Emma and Lillie.” Equally chilling reasons included “walking too close to a white woman” and “insulting a white man.” These are hauntingly familiar in an era when “wearing a hoodie” and “playing with a suspicious toy in the park” have resulted in death sentences.
How do I teach this? My parents and teachers likely faced the same conundrum. It is traumatic, unpleasant and profoundly sad to introduce my sensitive little boy to what occurred in this country that he loves. Desmond did not say much during our visit, but continues to be a kind, loving little soul. I hope he will draw on this experience to deepen his capacity to love and empathize as he grows up. Some will argue that seven is too young to take in such brutal images, but I know that waiting allows us to blame the victims of such acts.
The Living and the Legacy
At the memorial and the museum, though, you can see change happening. A connection is made that spans decades and geography. Conditions in the South led many to flee to the North and to wind up in places such as the Bronx—where I work—facing high unemployment rates, predatory crime and a legal climate almost as hostile as the one they fled.
Every American physician should make a pilgrimage to Montgomery, regardless of his or her creed, ancestry, national origin or place of employment. Black Americans are our patients, and we need to understand U.S. history to serve them properly. We need desperately to recognize how the institutions we revere have let them down, not just in temporary lapses, but consistently and throughout our history.
A clearer understanding of this history has alerted me to my own implicit bias, allowing me to work consciously to counteract its effects. For example, in my field of palliative care, many patients and families facing terminal illness ask, “Isn’t there anything else you can do?” This is often more an emotional response to terrible news than a concrete request. I now understand that for many black patients and families, this question is even more poignant, given their historic and frequent lack of access to the highest-quality care. Rather than reacting defensively, I can better understand the complexity and depth of emotion that may be involved and I can be more authentically present with them. Responding with enhanced empathy to black patients’ need for transparency and trust has allowed me to forge more-rewarding and more-productive relationships with these patients and families. Many people were interacting with the installations at the museum and at the memorial. Many were black. But there were people of all colors, genders and ages. We were all touching these artifacts, feeling and seeing them. Something transformative was happening there. We are beginning to understand this painful history as part of all of us—and, most important, learning from that history to help make the world a better place.