Umbereen S. Nehal, MD, MPH Profile picture
Sep 29, 2018 34 tweets 11 min read Twitter logo Read on Twitter
This 👇🏽
Not better as an attending. Support mechanisms for residents lost. Stress of liability & productivity metrics. “Ambassador” status remains. “You are one of the good ones” a lactation RN told me, “You follow the rules.”
@choo_ek @RheaBoydMD @Priyanka_Dayal @DrJRMarcelin
That lactation RN then said “My ancestors did not fight in the Revolutionary War 4 ppl to come here with their hand out” & “Slavery happened a long time ago. People need to get over it”

Identified as “one of the good ones”, she’d felt comfortable saying this to me on minorities
That left struggling with the cognitive dissonance of her words: how did she simultaneously take credit for ancestors fighting in the Revolutionary War (at the end, slavery was codefied into law until another war was fought to end it) and AlSO tell others to “get over” the past?
More importantly, reveals how she views the moms she is at work to provide care for, mothers tired, in pain from C-section, episiotomy, birth

Long before she had articulated this I had observed this attitude held by many front line staff that resulted in differential care
As “one of the good ones” I have to be perfect, not human/flawed

else lose that “good one” status and become like “them” in this “us” vs “them” world as she was defining

And if I mess up, have a bad day, as the ambassador of an entire race or religion, I don’t get to be just me
And yet, it is a Catch-22.

Being “one of the good ones” did not reflect well on whatever “other” group I represented to her

because what she was telling me was I was unlike whatever stereotype she held of people she put into my category of other

unlike herself who belonged
What she was telling me, in citing her Revolutionary War fighting (and slave owning) immigrant ancestors, was that she had a birthright — her behavior did not then need to meet certain standards — but I was acceptable only as long as I remained “a good one” of my “kind”
Having learned that my choices were either face constant microaggressions quietly or say something in return but then my response be labeled “political” and “makes people uncomfortable”, I chose to always chart in the back, apart from others, avoid interactions, isolate myself
This interaction happened when I was reviewing material for an upcoming meeting for this national leadership position on addressing disparities and improving health systems…

and she saw what I was reading and engaged me
Though I had been previously been advised that I was “making people uncomfortable”, these microaggressions were my job to accept and understand, I should accept being uncomfortable, and still perform at a level to maintain “one of the good ones” that allowed me to be there
A few months earlier, I had needed to get a birthweight error corrected. Chart showed 8% wt change. I assumed loss. Parents insisted gain. How could that be? Bedside RN said parents some photo. So I checked with parents. Pic of baby on scale vs EHR: numbers had been transposed.
Despite parents trying, very politely, be heard, to correct EHR error impacting their child’s patient care, no one was listening. “Is how they are hearing things” I was told. No, there was a verifiable error. Reminded me of @serenawilliams

@Priyanka_Dayal @RheaBoydMD @choo_ek
B/c, “one of the good ones” means gratefully accepting status quo, including harm. If one speaks up, “good one” status is lost.

Medical errors are the 3rd leading cause of death so happen randomly. But which patients are listened to to have errors corrected?
But as we saw with the recent SCOTUS hearing, that loss of “good one” status is also true of (white) women with every privilege as
@choo_ek tweeted recently. No amount of right schools or family membership in country clubs protects a woman

What we need to do is stop categorizing people by their demographics to assess who deserves to be somewhere

and stop telling people to be a “good one”

and allow everyone to be human and on the diverse spectrum of humanity
More importantly, when someone labeled an “outsider” like a minority, immigrant, not trained in that hospital, etc identifies an error

listen to them

Because system errors are there and affect everyone:
Black, white, orange
Him, her, their
Discounting or disregarding the “outsider” who identifies an error makes *everyone* less safe

In fact, the outsider is *more* likely to encounter the flaw and not know how to navigate around

System flaws do need to be addressed for everyone’s safety
Like maybe u know there is a pothole on a road & avoid it daily

If u do not report it to be fixed, someone else will drive into it & get a flat, maybe cause an accident

Maybe one day u can’t avoid the pothole as there is a person on a bike sharing the road. You get the flat.
Instead of penalizing, resenting person who files report to say, “there is a pothole that is dangerous and needs to be fixed”

(while everyone else swerves around it from habit and disregards danger to others)

Consider not only NOT penalizing that person but thanking them 🤔
Safety culture = work together to improve

reporting errors & system issues that can cause harm is how one fulfills “first do no harm”, ensures safety

But if assigned “outsider” status, not believed, then blocked from best practices of safety culture

We know there is wrong “shame & blame” already that is a barrier to safety reporting…

The pressure to be “the good one” as a minority physician, in light of @JAMA_current study on hostile environment and NOT report errors and incur retribution is high
Meanwhile, as a solution to disparities in care by race and gender, we are told “train and hire more women and minorities!”

Yes. Data DO indicate higher quality care delivered by women physicians and by minorities

Regarding superior outcomes and effectiveness of black male doctors to treat black male patients…
EXCEPT, given what I described above, that woman or minority (or both) physician is being ask to use individual excellence, in a hostile environment, to change patient outcomes

while, as “good one” NOT allowed to criticize the (flawed) system (else incur greater social censure)
“Hire more women/minority” physicians results in mere optics, as @RheaBoydMD eloquently described @AAPexperieNCE last year.

Dept photo showing lovely diversity.

System stays the same. Chews up and spits out the very same woman/minority hired to address disparities
Of course, yes, hire more #minoritiesinmedicine and #womeninmedicine

But what is measured matters

At end of year it is only productivity metrics reviewed (that matter to current system —healthcare IS a business, aligned with fiscal incentives)
So, again, another set up for failure.

Expect the individual to singlehandedly address disparities through personal excellence

while embattled with microaggressions,also never have any interpersonal issues with colleagues

AND see as many patients as efficiently as peers
We really have to add nuance to the glib “hire more women/minorities”

to identify the set up 4 failure

in already epidemic levels of burnout.

NOT about overwork but “moral injury”

and “ambassador” for race or “good one” is excessive pressure…
How do you induce moral injury? Hire someone 4 her individual excellence and “passion” to drive system change

assign her all patients with disparities/SDH issues (while peers earn higher productivity stats)

and then systematically penalize her for each time she fails to fit in
Change *is* uncomfortable

If you hire a true change agent, then accept (s)he will make others uncomfortable

Someone can either be the “good one” and seemlessky fit in with status quo


be a change agent and disrupt

Pick one goal and set consistent expectations
Have posted a few times before, but adding to this thread, as captures the set up for failure really “beautifully”, though a sad and unfortunate reality
When the minority attending is hired in a non-diverse setting

she the “expert” 4 minority, non-English speaking, high SDH pts

these pts directed towards her

She may genuinely provide more compassionate & high quality care

But emotionally exhausting & dec. productivity stats
And the “I hired a minority!” is a ✅

as the chief/chair goes back to thinking about grant funding, mergers, market share, referral base

Is can be akin to “but I have a black friend” ✅ on racism

and then disregard all the stats and outcomes that show inequity all around
Most minorities socialized & incentivized to remain “good one”

(consequences if not: not promoted, disciplined, job loss, loss of reputation, stress-related illness)

So if minority hired then expected to fit it

Is only optics, nothing changes

& high chance 4 moral injury

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