Episode 24: Racial Bias vs. Informed Patient Care with Dr. Carmen Black

Can we expect patients to trust modern medicine before addressing racial disparities in research and diagnoses? 

Dr. Carmen Black, Yale School of Medicine Assistant Professor of Psychiatry and Director of Social Justice and Health Equity Education, Adult Psychiatry joins this episode of The Menninger Clinic’s Mind Dive podcast. This conversation with hosts Dr. Kerry Horrell and Dr. Bob Boland explores how clinicians can make a meaningful impact while still facing centuries of racial disparities that are sometimes difficult to spot in daily clinical practice. 

Dive in to hear approachable steps clinicians of any type can take to address inequity and racial bias in mental health care. 

“We are more powerful to delivery equity than we can image because the disparities are so great,” said Dr. Black. “It starts with being able to acknowledge it in real time.” 

Carmen Black, M.D. is a family-oriented African American physician and strong supporter of racial diversity in medicine. Her research interests focus on promoting racial diversity within academic medicine and addressing influences on poor patient care, specifically racial and mental health discrimination. 

Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to never miss an episode of Mind Dive. To submit a topic for discussion, email podcast@menninger.edu. 

Visit www.menningerclinic.org to learn more about The Menninger Clinic’s research and leadership role in mental health. 

Listen to Episode 23: Brainwashing & Master Persuasion with Dr. Joel Dimsdale

Resources mentioned in this episode: 

Select publications by Dr. Carmen Black

The Menninger Clinic’s Continuing Education Black History Month Series

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Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.

Transcript

00:02

Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr. Bob Boland,

00:11

and Dr. Kerry Horrell. Twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives from the minds of distinguished colleagues near and far. Let's dive in.

00:42

Really excited we have Dr. Carmen Black. So Dr. Black is an assistant professor of psychiatry and the director of social justice and health equity for adult psychiatry at Yale University. She primarily works at the Connecticut Mental Health Center where she is able to provide quality clinical care to racially minoritized populations through her research, her research deals by the way, I'm going to add this end on promoting racial diversity within academic medicine and addressing iatrogenic influences of poor patient care. But this is what we're gonna be talking about. So I'm not going to go any further in this and just turn it over to you. So thank you so much for joining us, Dr. Black.

01:19

This is exciting. Yeah.

01:23

I mean, this really kind of started because I heard an amazing grand rounds from you, that you did for Baylor where you talked about, you know, really about, well, we'll get to that, but about ECT and why black patients were receiving less ECT. But before we get to the details of that, can you just tell us a little bit about your career path and just you know, what, how you developed your research interests, your interest in discrimination in patient care?

01:49

Sure, my interests came from having to cope and endure it myself. So I proudly identify as an African American woman descendant of enslaved persons. My grandparents were some of the first black PhDs out of the University System of Georgia. My mom was one of the first black women to graduate from a desegregated medical college of Georgia. No expectations, right.

02:11

Lord knows, I mean, we, I'd love to hear that story. By the way, if they're writing, if you're running their, their biographies, that's that that alone,

02:19

but yeah, you're right, like absolutely no pressure on, you know,

02:24

especially as I was a single mom in med school, then my brother died of a tragic brain hemorrhage during my second year of med school. And that's when I first realized that all of these data points of the so called racial disparities are people. We present them in scientific detached manners as if they're rats in the lab. But when I realized that my brother was about to become a data point in somebody's racial disparity paper for neurosurgical outcomes, that's when I first was sensitized to its racism. It's not a data point. It's not, you know, academic, these are my people. Yeah. And I became attuned to racial disparities are actually missing mother's missing Brothers failed justice to sisters, all over the US to black folks.

03:10

Yeah. And people want to know more, you wrote a really effecting really, very compelling article that's coming out in the American Journal of Geriatric Psychiatry.

03:18

Yeah, that came out 2012. And they might even say today article came out earlier this year.

03:25

Oh, boy. All right. So I do recommend that

03:27

well, and I, as Dr. Boland indicated, there's so much we could dive into in regard to the work that you've done and kind of the passions you're pursuing. But one of the reasons why we invited you on was because of this grand rounds talk that you gave on how black folks are less likely to get ECT. And one of the things that we know, we could spend the whole time talking about it, just reiterating that grand rounds. And we don't want to do that today, because we want to talk more about sort of tint more tangible solutions, and what are sort of the next steps. But before we get to that, would it be possible to summarize a bit and talk kind of briefly about why Black people are less likely to be getting this treatment?

04:07

Yep, I would even rephrase how we say that statement, I would say that medical racism fails to offer and deliver ECT at equitable rates to black folks, because so often, and medicine, we put the onus of responsibility of black folks being less minoritized magically, as opposed to looking at ourselves as a form of angiogenesis and taking ownership for what we're doing. So during the Grand Rounds, I briefly summarize that due to a long history of anti black medical racism, racial bias that's embedded within psychiatric diagnoses and practices render black patients as being less likely to receive accurate diagnosis of severe mood disorders by providers, accurate diagnosis of major depression, bipolar disorder, which also happens to be the diagnosis most indicated for ECT. So, providers are disproportionately inclined to perceive and diagnose psychotic features and black patients instead. And there are some emerging studies that having to endure systemic racism increases psychosis risk among black folks. And that's true. But what I'm also going to point out is it's still racism, that stuck heart of this inequity. And that still superimposed on the white normative misdiagnosis of psychosis in the first place. So the brief recap of the Grand Rounds is because of that long history of white normativity, and embedded anti black bias in psychiatry, the over representation among psychotic diagnoses, coupled with the under representation amongst the severe mood disorders, most indicated for ECT, coupled with factual histories of medical exploitation, as part of the reason that medicine fails to equitably, equitably deliver ECT to black folks. Wow.

05:49

That was an incredible, great synced great sounds summary.

05:54

Yeah. But the dial, I mean, right. So it's like a combination of misdiagnosis. And there's, as you as you may reference, plenty of literature about that. Yes. Right.

06:05

Can I ask a follow up? Just a quick one? Absolutely. And I unfortunately had I was not able to attend your grand rounds tonight. I wish I could have so tell me if I'm just I've missed it. And it's too much to go into but it makes me think does does this relate to kind of the long history of black folks having their pain minimized and kind of the the long medical history of folks people of color but a particularly black folks that like their pain is in believed,

06:33

it's all of the above, it's Henrietta Lacks, having billion dollar Cancer Research cells stolen from her, none of which went to her family. It's us being used for experimentation for gynecological surgeries, it's all the above, it's the past three years of COVID, where our communities have watched the media sensationalized our death on TV as if it's passing news, instead of realizing that this is our neighbors, this is us. That's my mama, that's at risk from COVID-19. So all of this feeds into the reasons why we don't and I daresay shouldn't trust medicine until we reduce all of these racial disparities papers come in on a dime a dozen every five minutes.

07:14

All right, I have one smaller follow up. I was just gonna say I think that's a couple of my colleagues who also kind of study similar topics. I think that's one of the things that they consult to us a lot on inpatient units is that when we have minoritized patients coming in, and they're mistrustful of us as staff, that that is not something to pathologize that ultimately they should be, or like they had, there's a lot of reason for that, that does not indicate paranoia, or lack of willingness to do treatment, that this is something to be really thoughtful about in regard to our patients who are coming in to a hospital to receive care, particularly psychiatric care, given this history.

07:53

Yes. And as it relates to ECT. Medicine has a hard time owning accountability for medical atherogenic racism in the same way that we do falls on the patient unit, or we missed the dose of anesthesia while we're delivering ECT. We have language of accountability in the moment for those form of iatrogenicists. But when's the last time anyone ever woke up on the inpatient unit and said, Ah, I think I was racially biased, just then. Oh, let me do a timeout. So I don't do that again, next time? No, we justify it with colorblind racism. And they didn't talk to us politely. They didn't do this. So they don't have enough support at home, we'll come up with 1000 justifications, which is completely opposite to every other form of AI exogenesis and psychiatric settings.

08:37

Well, usually patient wasn't cooperative always works well. But not to joke about it. I mean, take us through a little bit, you do a nice job in a recent paper that you wrote, either wrote or is going to be published about where were you sort of go through a patient is impressed. Okay. And, and that one's gonna be coming out where

08:57

the Harvard Review of Psychiatry.

08:59

Excellent. So another recommend it and it sort of takes us through a case. But you know, what? Cuz I mean, I think the average average clinician and it's mainly clinicians, I think, who listen to this, think like one of you some people do that. But, you know, I'm very objective when I interview patients, and I make a diagnosis based on what I see, and how could I be biased about that? So, you know, thinking through it, how, how does that happen, assuming that people aren't malicious about it, but yet it happens? Sure,

09:29

there's no malicious intent out there. No one wakes up in medicine, especially the younger crew like myself with $320,000 in student loan debt. We don't go through this effort and wake up to go harm minoritized patients. So the first thing I'll say is, is I will never put individual responsibility for systemic medical racism, but because our medical technology or medical understanding or diagnosis assessment is all based in historical, exclusionary white normativity Even myself as a black physician, I had to discover anti racism for myself because the knowledge being fed to me during my education was as white normative as anybody else. It wasn't until my brother died and other traumas that I realized, when I'm being sold in the textbook is not matching the reality of what's going on. It's by no one's individual fault. But we are all accountable. That's why using language if I exogenesis, we are all accountable for doing better. We've normalized inequity to racially minoritized folks to such a degree, that when it happens, we'll gladly write a paper retrospective, retroactive, quote unquote, racial disparities paper, I call them racialized, because there's nothing about my race that deserves this treatment, racialized, but when it's in the moment when the clinicians offering standard of care for privileged patient a, but the decision that makes the next racial disparity for minoritized patient be there's no language in that moment of accountability, because it's uncomfortable, because it's not compatible with our identities, and understandably so. So one of the biggest things I said at Grand Rounds is we need to celebrate detecting racism, because right now it's taboo. We don't talk about it, we don't talk about Bruno. But until we talk about it, how are we ever going to undo it? And that's the conundrum that we've set up for ourselves perpetuated by clinicians of all racialized backgrounds, is that we don't want to admit, when we're contributing to the next JAMA paper of inequity, even though we all are

11:31

that I that feels like, exactly it is the idea that we are all biased. Like in this example, you were saying, Bob of like, we you know, most people are like, I'm not doing this to be but we are all biased. We all have internalized ideas. I think we all have the capacity to be racist. And until we can talk about that until we can own acknowledge it, it does turn into this this experience of and one of the things that I love about our hospitals, we have a clinical Diversity Forum where clinicians get together every other week. And we bring consultation questions that have to do with issues related to diversity. And one of the things we we kind of promised each other in there is like, we're going to try to be gentle with it ourselves. So that we we can say, I'm wondering how my bias related to x, y, or z is impacting my care of this treatment. And until there's more safety to have conversations like that, I do think the gut reaction or like the quick snap judgment is like, Well, I'm not racist. I couldn't, you know, like, and then that just shuts off any reflective capacity to think like, Hold on What happened here, that what ideas have happened in my mind that that might have influenced the decisions I'm making?

12:36

I guess my question is, how could we not be I consider myself to be the expert of anti black racism. But I did not grow up in Puerto Rico, I am not Latinx, I would never show up to a predominantly, you know, Spanish-speaking population and try to tell them about themselves. But that's actually what white normativity does to every other race, we show up. And we pretend to think that those norms taught in medical school should be or could be, or would be the norms for everybody else. Instead of reinstating that our foundation, it only included one cultural aspect to begin with. So of course we are similarly as a world expert of anti black racism, I'm not going to show up to Asian folks and tell them about themselves. So if we just accept that, what I know is my own experience, it's not even about being quote unquote, racist per se, but just acknowledge your limitations of knowledge, so that you don't accidentally perpetuate racism by thinking you know, what you don't know, because you're too arrogant to know what you don't know, you know, that I

13:35

saw, I think I gave a grand rounds only a couple weeks before you on women's health equity. And one of the examples that we gave us, and I love this demo, because I think it's fascinating about for all sorts of different groups of people, but that the Stanford Prison Experiment, you know, they were wealthy white men who were part of the study. And yet the takeaway from it was something that people were it's global. This is gonna, this is what the human nature is in reaction to authority. And we've learned something human nature, and this is still what's taught in our textbooks today, of like, this is from this study what we've learned about something like human nature, and I would love I mean, granted, it's unethical. So like, I actually wouldn't love very important caveat there. But in theory, would love to see what that experiment looks like if we swapped in different groups of people, because I think it come out incredibly differently than what they found with again, a particular group of

14:24

right wealthy white men. Yeah, well, you could say the same thing about DSM. And

14:28

that's the point. It's like one example of like, psychological tests that so much of our our theories that quite literally have built psychiatry and psychology are built on a very particular group of people. And then we were saying, This is what human nature is, and how we then can treat everybody. I'm sorry, I'm just I'm off. I'm off

14:45

your butt. You're getting give me I don't know. Do we have time for a little history lesson or? Yeah, I mean, always right. Because once I mean, you know, I don't think certainly I never learned until I investigate on my own and I don't think others have learned like that psychiatry has a pretty checkered history when it comes to really any non white group. And you want to going back really to our founder like Benjamin Rush and stuff, and at least I found in America.

15:11

Yeah, he's a, he's considered the father of American psychiatry. Yes, right,

15:15

of the American signer of the Declaration and all that I wouldn't. That's that's about as much as I learned about him and stuff. But I mean, you want to take us back a little bit and sort of say why people might mistrust psychiatry, if they're not white, or male. It's all

15:29

about embedded white normativity. So each problematic link in the chain is a product of their time, their biases, and the ongoing exclusionary practices that limit minoritized voices at the table. So Dr. Benjamin Rush also believed on top of all the awesome stuff he did for the privileged people he treated, he believed that black people skin was a form of leprosy, and that if you cured us, we would turn back to the white color that the good Lord Jesus minutes to be in the first place. So that's literally white normativity and in white supremacy. And Dr. Rush was also the mentor of Dr. Samuel Cartwright, who came up with the diagnosis of drapped, Romania, which is the mental illness where enslaved persons just didn't appreciate their overseers like they should. And they must have been crazy to keep wanting to run away from the goodness they had an implantation. And he also came up with my other favorite diagnosis, which is dishonesty to Ethiopia, which is where you are mentioning the desensitivity of black skin. Well, Dr. Cartwright literally taught that we were so lazy, and our skin was so insensitive, that you had a whip us in the sunlight and put us to work, the curious they call it that beneficence. And so this myth of we don't have pain sensitivity on top of did we even have the freedom to, you know, object to our exploitation? These are the undertones leading to psychosis being associated with civil rights movements and Black Panthers in the 70s. It's, it's all there. But until we learn our history, we can't detect the remnants and legacies of this history and current clinical practice.

17:15

Yeah. And even though it's so long ago, I mean, that's it's really not I mean, that there's I'm trying to come up with plenty of more recent examples to have.

17:24

Absolutely, I mean, ask any black person what they were thinking, watching all of our people publicized dead about COVID. And we know it's inequity, even if the privilege folks, excluding our representation amongst medical providers won't acknowledge us, we know for ourselves without anybody else's permission, that the reason we were dying is because of racism, even if nobody else wants to acknowledge that.

17:48

Right. Right. Gosh, and you know, even though we want to, like think that that's in the past, and now we've, you know, we've we've turned a corner and stuff. I guess that's probably just wishful thinking, right?

17:59

Completely wishful thinking. So, back in the day, when my mom was going through medical school as one of the first black women, we had overt racism, the Jim Crow, racism, colored ward of the hospital, whites only ward of the hospital friend of us back and boasts, it was explicit, it was overt it was not sugar coated, you deserve this because you're black. But we don't have that language anymore. So those of us that want to believe that racism disappeared when it actually just changed his language. So when it comes to ECT, it would be you know, the beginning example, black people don't receive ECT. No, you don't receive abuse abuses perpetuated. And the one perpetrating that abuse is we, the providers, all of us, myself included, even as I continue to eradicate normative thinking. And so what we need to realize is that we're using non racial language from a limited perspective of privilege to justify racist acts. So for ECT, it would be all black folks don't trust us enough to consent for ECT. Why not? I would never trust him. Those racial disparities are somebody else's problem. My department has a DEI (Diversity Equity and Inclusion) Chairman, my department has this my my practice my department, my university is somehow exempt from the umpteenth JAMA paper this week. And that sort of like magical thinking is part of why we have a hard time wanting to and successfully identifying racism in real time, clinical practice today. It's utterly magical thinking,

19:34

well, and I'm even thinking about the language piece. I had not thought about that even just saying black people receive less easy tea, that that again, just like there's so much subtle blaming that we do, and I think shirking of our own responsibility, and what role that we have to play in a

19:53

that's one of my newest papers and journal of racial and ethnic health disparities, called Words matter. It's a whole lesson every rephrasing how we talk about racialized inequity. Because I had to teach myself can you say,

20:06

you want to tell them more about that? Absolutely. So

20:09

I myself was taught the language of academic medicine, which is people receive inequitable outcomes, they experience poor outcomes, they are 14% more likely to wake up dead. But what I realized is I was going through again, galvanized by the experience with my brother, when I realized that his injustice was now a data point, the way we talk always is in the passive voice or emits the agent of the action. So let's go back to grammar one on one real quick, the cat ate the mouse. Right? So the cats doing the action, which is eating and ate what the mouse? So in the active voice, it would be medical racism harms black people, heal wiggle room clearly identified. But instead, what we say is the mouse was eaten eaten by who? I don't know, by what, I don't know why so black people were less likely to get ECT. I don't know. So those subtle language tricks where our responsibility just magically disappears, is very powerful, and ironically, not ironically. But the APA Manual of Style, the AMA Manual of Style, they all say right in the active voice. But no one's recognizing that were violating our own tenets, when it comes to racially minoritized folks will always put it in this passive voice and likely leave off the agent who's doing the action in the first place. So it's not that black people are receiving less ECT is that medical providers are offering delivering thinking about it less often.

21:44

Well, yeah, but the passive voice is good for eliminating our guilt and pain.

21:49

That's the thing is, it's like it's also it's still harmful, because it's just perpetuating white comfort and people just not having to think about it. Let's not think about that's uncomfortable. We don't want to have to think about our own

22:03

responsibility responsibility for agency, I suppose. Exactly.

22:07

biochemist would never a biochemist would never, you know, any other field of scientific inquiry would never. And we in medicine, don't ever talk like that. If we're doing a cancer study. We're not going to talk about the cells were decreased. Hmm. Great. Wow. But who, what, when? When we're talking about minoritized votes, do we become so vague? So it seems like should I

22:31

trust you a better run some people? There's all kinds of passive voice problems. So we won't go into that. I'm guilty of that. I'm

22:37

be honest anyway.

22:39

So I guess one of the things that it sounds like I know I'm curious about and it sounds like people who've listened to your grand rounds were also curious about is, what are some of the things that we can be thinking about that to be part of the solution? And what are some of the things that we can do as mental health clinicians to be remedying and moving this issue

23:01

forward? So the first thing and in Grand Rounds This is all I got to say is just celebrate detecting racism, celebrate it, talk about Bruno. Invite him, sit down, ask him his experiences, because

23:16

let's talk about

23:19

okay, sorry, go ahead.

23:20

The Disney thing it's from Encanto. Okay, an amazing movie, and you should see.

23:24

Okay, I'm sorry to interrupt.

23:26

You ask the question.

23:30

Watching in content, yes. Okay. You're

23:32

coming back for another episode. Thank you cancel.

23:37

Yes, yes, yes. Anyway,

23:39

I'm sorry. But please.

23:41

So we won't talk about the elephant in the room. I'll use that example that one I got. So we need to celebrate detecting racism and talk about the racist elephant in the room. If we're just even willing to humble ourselves to that degree. We already have an entire literature base of racialized inequity papers that exist in a complete and complete complete silo from real time clinical practice. Again, we want to read the JAMA papers about racialized inequity come in on a dime a dozen. But when we go see our patients, somehow our minds are completely detached. So one of the things that I mentioned was almost like a racism timeout. And most ECT capable facilities are attached to some type of academic medical center just for resources and stuff. Most, at least many when so use your med students, we are all busy up the wazoo but making a teaching moment because we all have teaching moments I educational centers, so when I read did the diagnosis of my racially misdiagnosed black patient, my med student did the legwork. She did the chart digging, and so make it a game. Oh, wow. I have Mr. Jones. Mr. Jones is a 50 year old man being referred to ECT for treatment resistant psychosis. But I remember that pain you've heard that black folks get misdiagnosed by providers more often. And I remember so many papers. Before do this referral, I want to make sure that Mr. Jones is actually psychotic. So I'm gonna go through the chart and I'm not going to intentionally give any mention of paranoia, less value, unless it's something completely out of context to reality, like green aliens with pink antennae are coming down at night and eat and peanut butter sandwiches. Okay, if that's your paranoia, welcome to psychosis. But if it has any flavor of reality, then I'm going to need to intentionally decrease that and my differential of psychosis. We also know that when folks are using substances racially minoritized, folks were more likely to assign a primary psychotic disorder diagnosis said considering is it substance induced? Do we give time for a washout period? So I'm going to look and see if substances were on board when this patient got a psychotic diagnosis?

25:53

Hang on, just for a second? Because I want to can you make a bigger point about that? Because that is interesting that the role that substances might play, because right anyone on certain substances can get paranoid, for instance,

26:04

yes, but what will happen is that for privilege, folks will get diagnoses of like, rule out substance use substance induced mood disorder, right or rule out this rule out that, but when we're already primed to consider black and brown folks of having psychosis, if there's a willful psychosis, instead of doing our due diligence to make sure there's a washout period and make sure you know, something else isn't going on, we'll assign the primary psychotic disorder, as opposed to couching it the way we would for a racially privileged person in, oh, I don't want to label this psychosis primary yet. Let's wait a minute and make sure. And so that's one of the things we need to watch out for. And also psychosis is a symptom of many different disorders. You can have major depression with psychotic features, which the data says black folks are more likely to get referred to ECT. If providers proceed psychotic features, even amongst those was with an MDD (Major Depressive Disorder) diagnosis, that can be a part of that bipolar diagnosis. Right. MDD and bipolar are both more likely to be referred for ECT or can be part of trauma. If you don't understand what it is to live a minoritized life, there is no post to your traumatic stress, white supremacy and systemic racism. Make sure you're getting hammered every day, there is no safety. You don't get to wake up one day and say, Oh, I'm so glad that's over. And so we might be misunderstanding, trauma experiences as psychosis as well, or cultural manifestations of trauma representation, symptom expression as psychosis. So it's our due diligence to find fun ways. It's actually really fun because when you talk about the racist elephant and you find its trunk, haha, I am a superstar because every clinic ever over there, their trunk is in the dark still there, they're still thinking They're magically immune to JAMA's racial disparity paper. But us. Oh, look at us. I found the trunk to the elephant. Let me see if I can find the foot too. If we celebrate detecting racism, how much good can we bring to pay people as opposed to wanting to wish ourselves immune to history? Immune to racialize injustice immune to JAMA?

28:20

Yep. So bringing a lot of skepticism in. Were you thinking other things that are already been just not taking at face value? Well, we see

28:28

that confirmation bias and anchoring bias, perpetuate that taking it at face value. Because Oh, my colleague, Dr. Jones, Dr. Jones has been here for 30 years. Well, if Dr. Jones says that this patient is psychotic, well, and their seniority I totally believe that they're psychotic, even though again, I'm going to function in isolation from all the papers that say, you know, this patient, right has a four times chance of being misdiagnosed as psychotic compared to a white one. Right? So that's tribalism because we want to believe that I would never do wrong until my colleagues can never do wrong, or we want to think that seniority erases their ability to do wrong, anchoring biases. Well, we've, the first thing I see is psychotic features. So of course they're psychotic. Confirmation bias is when you suspect something now I'm going to selectively listen for psychotic features and dismiss mood features. Matter of fact, there's a paper that says even when providers detect mood symptoms, we decrease their relevance and the differential of building a diagnosis.

29:31

Do you think that having using any sort of like objective, that's probably not the right word using some sort of measure like an IAT (implicit association test) or like some bias measures, like somewhat regularly as providers would be helpful? Like that's one of the things I'm thinking about is in the sense of celebrating when we when we find and we recognize racism, and I think part of that is exploring and recognizing our own biases and making space and normalizing that like, we are biased that is that is That is so a part of being human is ever going to have biases. And so how do we take time to spend time trying to to sort of shine lights on those and get to know what our biases are? And, again, my mind goes to like, implicit association tests or other sort of, so

30:13

my answer might surprise and disappoint you.

30:16

Oh, okay. I'm

30:18

brave. All right, go.

30:19

I don't believe in training. Nope. No, I believe in accountability, such as what we do with every other form of iatrogenicis, Dr. Jones, I see because we all got electronic medical charts, right? I can run a test by racial diagnosis and see if you're delivering inequitable outcomes. Dr. Jones, my little push of a button here shows that you're giving white patients great care. But the computer tells me that your black patients ain't doing so good. I'm gonna give you some chances. And some I'll train you then. But training in the form of accountability, because no one can counteract 400 years of racist nonsense on their own. Right. That's not fair. But I believe in accountability, because that's what medicine does for iatrogenicis, we don't train them with wishful thinking, we hold people accountable, you are accountable to my brother, you are accountable to my mother, you are accountable.

31:08

I'm glad to hear that, in a way. Because I mean, so often when I see literature about it's about, you know, that we need more education. But I have to say I'm a bit cynical about the value of education to change with maybe fairly ingrained human behaviors that are probably not even

31:23

if I didn't believe in education, I wouldn't be a medical educator, I'm

31:26

not totally trashing education.

31:29

And accountability. What if the privilege were held accountable to the minoritized? Yeah,

31:35

okay, fair enough.

31:36

We need structure, we need expectations, we need systems. Yeah.

31:41

And I guess we just need to be you know, and it comes down to it's a lot of work

31:46

400 years, you can't do that one grain wrong

31:48

quite well, because you're really sort of like countering your own biases, kind of, I mean, kind of confirmation bias is just so natural. That takes it takes energy, not to just fall into

31:58

that. And that's why I suggest using med student labor, because we all know our schedules are something awfully built by the medical industrial complex. You can't do that in a 20 minute med check. I'm not even saying try. But what I am saying is med students are there to learn. And that's where medical education can be this tool of social justice, what if they got, you know, excellent honors, found three patients that they could read, diagnose, right? What if we used med student labor to teach us because that the new wave is steeped in fewer biases, and those of us who've been doing it year by year and longer and longer getting more and more habituated to racial disparities as data points. So also, the diversity and representation of the new wave of med students is more diverse. It's still completely inequitable for black folks, especially this in that time slave persons, but as more diverse than existing faculty. And then as we have ideas of medical professionalism we need to hold when people challenge our authority, Dr. Black, well, I hear you on the X, Y and Z towards a psychotic diagnosis. But I would like to be exploring a, b and c, without being reprimanded for resistance feedback. Dr. Black, I think you're wrong. Where's the medical professionalism that can hold challenges? Because what if someone does detect the racist elephant trunk and tail two feet? Oh, but then if I challenge my attending as a subordinate, well, that attending therefore reprimand me in the hierarchy of medicine, right, for challenging them or creating a hostile learning environment? That's a whole master's thesis I'm doing right now.

33:36

Really? Have you seen that slowly changing? I I'd like to think it is as a older person that that that people see it more collaboratively now the learning experience than it might have been? Or is that just my wishful thinking?

33:48

Is it double sided? In the

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sense I feel like I learned a lot from younger people, obviously. And that's, you know, and I don't know, do you think I'm Richard, I? Do I punish you? If you disagree with me? I don't know. No. You're not gonna say, you know, I'm here, of course, but

34:06

slowly shaking.

34:10

We'll talk later. Okay.

34:11

I think ironically, the more we talk about it without dismantling the racism, the more our project, our fragility builds up when we're actually challenged in the moment. Well, what did you lose by us? I took extra trainings. Well, what do you mean, I took an extra CME (continuing medical education) course. Well, what do you mean? Of course not. I read the book, what do you name right? So it allows more coupling, training, education, wishful thinking, Kumbaya, handhold, and sing and chant. And that's where coupling that with accountability and holding physician activism as the purest form of medical professionalism, we're not going to get much further, but I will say my career in completely authentic non code switched fashion couldn't have existed 30 years ago. So are we getting better? Yes, because a few of us exist. saying, my trainees call me Dr. Blackity Black for reason. Get out. They do they do.

35:08

Dr. Black. This has been incredibly informative. And I appreciate your candor, and your wisdom that you bring to this topic. We really appreciate you coming on and sharing with us.

35:20

Yeah. And we're gonna give you the last word. Any last advice for our listeners and for us,

35:24

because the inequity is so great, every one of us has the chance to be rock stars, if we'll just celebrate detecting racism, as opposed to forcing ourselves to somehow magically be immune to the racial disparities papers. We are more powerful to deliver equity than we can imagine because the disparities are so huge. And it just starts with being willing to acknowledge it in real time.

35:52

On that very positive note there we end and thank you so much, Dr. Black. So once again, we've been listening to Dr. Carmen black, and I am your host Bob Boland.

36:02

I'm Kerry Horrell, and thanks for diving in.

36:06

So this month is the Menninger clinics free continuing education program for mental health professionals features a special series for Black History.

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Join us online Friday, February 10. At noon central time for historical radicalization of substance use, presented by addiction psychiatrist Dr. Daryl Shorter, who is also a former guest of Mind Dive. 

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And on Friday, February 24, at noon, central time, the topic is addressing the crisis of suicide in black youth with psychiatrists, Dr. Carolyn Barnes presented

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to sign up for these free programs. Click the link in the show notes or visit Menninger clinic.org. Choose for clinicians and then continuing education. We'll see you there. The Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

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For more episodes like this, visit www.menningerclinic.org

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