Sunday, January 19, 2014

Diversity and Care

There are some things you learn from books and school. Some things you learn from others’ experiences. Some things you have to live through to really understand. Finally, some things you learn through the collective memory of growing up in a culture, and with a history that is passed down from generation to generation and that is reinforced as part of your growth and development.   In healthcare, we learn from patients and others in need every time we interact with them.  However, what we learn and how we learn will always be limited, to some extent, by our own lack of having lived through the experience and by having a different collective memory -- no matter how caring, skilled and empathetic we are.  I am reminded of this every year at Martin Luther King Day as, for me, that day is the embodiment of my belief that we must acknowledge how we are different in order to respect and appreciate the unique characteristics of each person and the collective memory that shapes each one of us.   

My own collective memory is shaped by the reminder -- every year at Passover -- of my tradition that I was a slave in Egypt.  It is shaped by being an inheritor of Abraham, who was a stranger and also welcomed strangers, as I am kind to those who are strangers as they arrive on these American shores and as they migrate across our country.  My memory is shaped by Emma Lazarus’ words on the Statue of Liberty to “Give me your tired, your poor, your huddled masses yearning to breathe free”; those words inspired my parents as they came to the United States, passing through Ellis Island and New York Harbor. It is shaped by my remembering my uncles and aunts who perished in the Holocaust and truly feeling their pain and their helplessness.  I can’t help, when I meet people, wanting to know if they are “members of the tribe” -- fellow Jews -- and I make no apology for that desire. 

On Martin Luther King Day, I think about those friends and fellow Americans who lived through slavery, repression, and bigotry -- and who still live through it -- sometimes directly, but even more often through the collective memory that is part of their unique heritage. I think about our need as a society to address not only the reality of bigotry and intolerance, but the feelings and the values that this memory invokes in all who share it. This type of collective memory is not limited to race and religion, but also is seen in gender and sexual preference.  Women grow up with a shared memory of struggling for the right to vote, of being blocked from education and opportunities, and even of the unique aspects of childbirth and motherhood, for example, that men can never fully incorporate into their own psyche. 

This weekend I had a vivid example of that difference in experience and collective memory when I had the opportunity to attend a fundraising reception for Spelman College, a historically black college for women in Atlanta.  I spoke to a bright idealistic young woman --originally from an upper-class neighborhood in the San Francisco Bay area -- who told me that the decision to go to Spelman was “the best decision I ever made” because growing up, she was always just the “smart black girl” at mainly white schools. At Spelman, where everyone was a “smart black girl,” she was able to find her own individuality and set her goal toward being a doctor in Oakland. 

Two articles caught my attention as I thought about all this.  The first is a short study entitled “Minority Physicians’ Role in the Care of Underserved Patients: Diversifying the Physician Workforce May Be Key in Addressing Health Disparities.”  The study points out that non-white populations have a much higher proportion of non-white physicians and makes the argument that to address underserved nonwhite populations, we have to train more nonwhite physicians.  “Nonwhite physicians provide a disproportionate share of care to underserved populations.  Hence, increasing the racial and ethnic diversity of the physician workforce may be key to meeting national goals to eliminate health disparities.” That young woman at Spelman is headed toward filling that need for nonwhite physicians, and we should be grateful to her and to Spelman College for that commitment.
When I was in practice on the south side of Chicago, the majority of my practice consisted of black Americans.  I realized that while I believed I could relate well to my patients by digging into my own collective memory of being the Jewish minority, I could never fully understand the unique generational memory that my patients had. I had the good fortune of taking that as a challenge to learn from them -- and that helped create the relationship between me and my patients.  At the same time, I know that my physician colleagues who were black could relate and be trusted in a way that, for me, could only come with time and work, and even then, could never match the brotherhood that was possible when the collective memory was fully shared. 

At the same time, the differences between us cannot stop or impair care from happening. The bigotry that sometimes accompanies group identification that is too strong must also be acknowledged when we care for people in need.   Dr. Meghan Lane-Fall writes about the dilemma of a black physician and a white bigoted patient in an article entitled “Accommodating Bigotry.”  The question she asks is whether patient autonomy and patients’ right to make decisions for themselves is so important that issues of bigotry should be sublimated to the patient’s right to decide on the professionals caring for them.  She writes, “Does patient-centered care, then, justify tolerating bigotry?  In my opinion, yes.  I cannot countenance bigotry and other forms of prejudice, but my discomfort with a patient’s belief does not trump their right to specify the conditions of their care. It is my hope that by affording all patients with the respect that was so often denied to my forebears, the questions I have considered here will eventually become irrelevant to the practice of medicine.” 

I share Dr. Lane-Fall’s hope that the question she asks will be unnecessary, and at the same time, do not expect or even want a world in which there is only one collective memory and set of values that all cultures agree on.  For me that would be a boring world indeed.  Instead I hope that we develop the capacity to acknowledge and celebrate our differences. The part of my collective memory that is distinctly American is a strong, almost religious, belief in equality of opportunity and pluralism.  Acknowledging that while there may be one path for me, others will have different paths that are as valid and as strong as mine.  That is the American dream and the American ethos.  I hope in healthcare and in all aspects of life in these United States, we come to a point at which we celebrate the pluralism, recognize those differences, and plan and act accordingly. We should encourage more diversity in the healthcare workforce, on boards of directors and in the “C” suites of corporations -- and see it as the strong positive it is. It is, in many ways, what makes America so great.