Black and Blue. John Hoberman
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puts them beyond the judgments of observers who do not belong to the guild.
The physician's authority and autonomy can promote a socially conservative identity that resists both personal self-examination and social reforms. Social conservatives may not see the causal relationship between self-scrutiny and a willingness to promote social change, including the profound social changes that antiracist policies require. Even today, social conservatives (and others) retain the option of preserving the traditional racial hierarchy and its racist folklore inside their heads, while conforming to antiracist public norms that enforce public civility and a degree of racial integration within “disciplined” workplaces such as hospitals and clinics. There can be no doubt that many doctors choose this option, thereby disciplining their social conduct but not their racial imaginations.
Given the degree of autonomy traditionally accorded to doctors, requiring them to examine their own feelings about race, and perhaps change their behaviors, will be regarded by many of them as an invasion of privacy. Whether doctors are entitled to this privacy depends on what privacy may conceal. If it is true that “few people are free of unconscious fantasies about imagined racial characteristics,” as one prescient physician wrote in 1985, then the existence of unconscious fantasies with potential medical consequences challenges the right to privacy of the doctor who harbors them.25 According to the prominent physician and author Sherwin Nuland, “conscious and unconscious prejudice pervades rounds, teaching conferences, and even decision-making.”26 In a word, it can be medically dysfunctional for physicians to preserve and act upon their “private” racist fantasies and beliefs.
Another traditional aspect of physician privacy is the right of doctors to be apolitical and uninvolved in public policy. As two proponents of medical curriculum reform wrote in 1994: “Although organized medicine may occasionally take a stand on matters of public policy and bioethics, such positions are often weakened by medicine's long-standing position that individual physicians cannot be expected to act contrary to their own moral beliefs.”27 While this position appears to defend acts of conscience, some physicians will find it difficult to distinguish between their moral beliefs and their intuitions about racial differences. Those who believe that the traditional Western racial hierarchy is an expression of natural law may well reject the positive (man-made) laws that mandate racial equality. In such cases, how will apolitical and social policy-averse physicians establish relationships with black patients? These patients are, after all, people who require sympathetic racial attitudes on the part of those who treat them.
The racially “conservative” physician thus finds himself in a difficult position, caught between the demands of modern racial etiquette and his own private beliefs about racial traits and differences. It is, therefore, not surprising that the medical school instruction in “cultural competence” that is designed to resolve such conflicts has encountered much resistance for this and other reasons. It is easy, for example, to argue that an already crowded medical curriculum simply has no room for “touchy-feely” instruction in human relations that displaces courses in the “hard” medical sciences. Many doctors who are asked to expand their emotional repertories to include new attitudes toward blacks and other racial groups will reject this as an unreasonable and unrealistic demand on their emotional resources that amounts to a violation of personal privacy.
For this reason the very idea of asking doctors to examine their own feelings for the purpose of better serving their patients already represents radical reform. Integrating the race issue into this process is a further complication that many doctors will interpret as mandated political correctness and unrelated to improving medical treatment. Another factor involved in requiring medical professionals to engage in self-examination is the emotional stress that is often a part of medical practice. The ER doctor Paul Austin has thought deeply about the emotional costs of his medical practice and reached some conclusions that depart from the stereotype of the “caring” and “compassionate” physician. Compassion “isn't an emotion. It's an action. A discipline.” Similarly, “emotional distance may not always indicate a failure of empathy.” Austin recognizes both the practical value and the costs of emotional distance, which can promote emotional survival but also repress feelings in ways that can eventually harm both the physician and his patients.28
Doctors may also find the task of introspection time-consuming and impractical. “Frequently physicians think that dealing with emotions is opening a Pandora's box, that they'll be asked about things they can't do anything about, and that it will take a lot more time—especially if the feelings are about sadness or anger.”29 Inside this Pandora's box lurk the devastating consequences of poverty and family trauma that impact the lives of black patients in a disproportionate way. And it is true that the doctor can do little or nothing in a direct way about social conditions or dysfunctional relationships. What the doctor can do is to study his or her own responses to traumatized people. This process should make it possible to distinguish between the unique identity of the patient and the racial folkloric traits conveyed by the oral tradition described later in this book.
The idea of providing or requiring psychotherapy for racially prejudiced physicians has been heard in the past and has gone nowhere as a way to prevent medical racism. “For psychiatrists who lack the empathy needed for work with all groups of people,” David Levy wrote in 1985, “psychoanalysis has been recommended to erase distorted perspectives concerning race or at least to enable them to become more aware of when their irrational attitudes might impede the treatment process.”30 Two decades later the same proposal appeared in Academic Medicine: “When they are not brought to the level of consciousness, physicians' personal attitudes, biases, fears, emotional reflexes, psychological defenses, and moods can interfere with their abilities to arrive at an accurate diagnosis, prescribe appropriate treatment, and promote healing.”31 From the perspective of many white physicians, therapeutic intervention will be construed as an intolerable intrusion. From the perspective of many black patients and physicians, the therapeutic option may be regarded as the least the profession can do to protect them from racially motivated mistreatment. Once again the professional's right to privacy confronts the patient's right to unbiased treatment.
THE ORAL TRADITION
Physicians' “private beliefs” about racial differences can have effects that extend beyond their own medical practices. The physician's private sphere also takes the form of an oral tradition that conveys racial folkloric beliefs from one generation to the next. In 1983, for example, a paper in the American Heart Journal raised the question of “whether a 'traditional' diagnostic belief exists that blacks simply do not develop myocardial infarction.” That “traditional” belief did, in fact, exist, and has persisted, as this book will demonstrate. Interestingly, this author is unsure as to whether this belief was real, and he suggested that “a broad survey of physicians' beliefs and attitudes on these issues” would be in order.32 Three decades later, this and other surveys of physicians' beliefs about racial traits still have not been done. While the racial history of American cardiology does appear later in this book, the survey proposed in 1983 would have done far more to improve the care of black heart patients.
Medical students, too, can participate in this process. As a former student wrote to me in 2005: “One of my MCAT class teachers is finishing his 3rd year at [University of Texas] Southwestern Medical School now. He tells us interesting things about the patients he sees. For example, he has observed that African Americans are genetically more athletic than other races (overall), but they also have a much greater risk of having high blood pressure and certain types of cancer.”33 We may assume that the genetic reductionism that prompted this medical student's imaginative claim about athletic genes continues to thrive alongside other bits of uninformed gossip in “the oral culture of medical training.” For this reason all medical personnel should keep in mind that medical gossip thrives, “not so much at the bedside (medicine's preeminent metaphor) but via its more insidious and evil twin, 'the corridor.'”34 African Americans know and fear this oral tradition as “the silent curriculum” that many white doctors carry around in their heads. But the positive image of the medical profession, along with the racial imbalance of power that conceals much black suffering, has effectively shielded the oral tradition from public scrutiny.
PHYSICIANS