So, racism is firmly on the agenda. Again.1 The differential mortality of individuals from Black and other minoritised ethnic groups, including doctors, from COVID-19, has forced the issue of racism in health care to the foreground. But why has it taken a global pandemic2 and the murder of George Floyd3 for this shift in attention to happen? And most significantly of all, why has it proven so difficult to effect real change in the nearly two decades since de Wildt et al ’s powerful call to action in this journal?1 As two psychologists working in medical education, this is a question that we have both been grappling with.
PERIPHERAL VISION
Lawson4 provides the first clue in an earlier BJGP editor’s briefing, when he describes how GPs have kept inequalities ‘on the periphery of our vision’. With a growing older population, ever more patients presenting with complex comorbidities, and a global pandemic and the overnight transition to telemedicine, overstretched GPs would be forgiven for feeling they have quite enough to fix already. It’s not surprising if these structural demands squeeze out a GP’s capacity to see beyond — and think about — what’s in front of her. But even if she wanted to turn to look squarely at the issues, there are additional challenges. Gill and Kalra5 provide the second clue with their observation that ‘all lives are not equal’. It is so tempting to rush over this statement and focus on the important, but ultimately sterilising statistics of racial inequalities in health.
TURNING A BLIND EYE
The implied notion that the system protects some lives more than others is anathema to medical ethics, professional codes of conduct, professional identities, and the reasons why we went into the caring professions in the first place. In fact, as Gill and Kalra argue, it is precisely because the caring professions are supposed to care that ‘it is often too easy to overlook our culpability in sustaining and reproducing racism.’ 5 Stark words. But perhaps it is time more of us asked ourselves difficult questions: have we ever reassured ourselves that the higher MRCGP failure rate of international medical graduate trainees can be accounted for by differences in the quality of medical training in their home countries, language difficulties, or cultural factors that impede communication? Have we ever explained such discrepancies in this way without going on to ask ourselves why significant differences in MRCGP pass rates are also found between British, UK educated, white and ethnic minority trainees?6 The challenges faced by GPs are also exacerbated for those from minoritised backgrounds, because of social and occupational penalties,7 especially when asking these very questions,8 and the traumatic impact of racism.3 It is hard work (psychologically speaking) to take on board the notion that all of us are part of the culture that underpins these sorts of racial disparities. Psychological defences mean we are adept at not seeing9 what would otherwise cause moral injury. For GPs from minoritised backgrounds who have no choice but to see, bringing attention to structural racism may have additional psychological costs: instead of being joined in taking a long hard look at the system, the gaze may fall on her as ‘the problem’, this shaming stare inducing stereotype threat,10 where she must carry the weight of society’s negative stereotyping.
LOOKING INSIDE
Of course not everything has stayed the same since the landmark publication of the Macpherson report in 1999, which forced the establishment to confront the notion that societal racism was embedded and systemic.11 In 2020, the inclusion of clinical commissioning groups into the NHS Workforce Race Equality Standard for the first time was welcomed.12 So too, were the comments of the Chair of the General Medical Council, Dame Clare Marx, in her foreword to the 2020 report on the state of medical education and practice:13
‘This is no longer a question of gathering evidence, but of committing to action. We know that the experiences of doctors from a BME background can be sharply different from those of their white colleagues. It is now a question of what we do about it […] This work is critical …’
Yet top-down directives still have to be counterbalanced by a sense of grassroots involvement in local efforts to tackle racism.1 Despite the potentially painful challenges to GP identity, accepting personal responsibility may be less persecutory and more enabling than the alternative stance of consigning issues of racial discrimination to the periphery of one’s vision. The abstract vastness of systemic racism can leave individual practitioners and groups of GPs feeling powerless and alienated from solutions. Recognising that we are all part of the system may help to engender positive action from the frontline. An excellent example of this is the North West Paediatric Dialogue on Race (https://www.paediatricdialogueonrace.co.uk), which is a peer-led collective creating inclusive spaces to discuss race in the workplace. If we can’t talk about racism in our workplaces, how can we tackle it? Modest as dialogue may seem, it creates the human connection necessary for collective action. Survivor activists and multidisciplinary professionals, including GPs, have founded the London Aces Hub Racial Justice Workgroup14 to shed light on the impact of racial trauma and facilitate collective action to tackle these harms for individuals and the community. More top-down support for paid and protected time for such reflective practice would have the twin benefits of reducing professional isolation and burnout that has increased during the pandemic,15 and make more room for race equity in health.
LOOKING AHEAD
The pandemic has destroyed and disrupted lives. But it has also shown how human ingenuity for communication continues unabated. Even though it lacks the richness of in-person contact, haven’t we all been surprised by the ways in which good patient work and teaching can happen through virtual means? Anecdotally, one of the authors has found that Balint groups survive more-or-less intact using an online format — a finding that was echoed in recent medical school data from Germany.16 Perhaps this could be the moment when groups of GPs from different cultural backgrounds and locations could get together virtually in order to listen and learn to share and bear the struggle necessary for social change? Racism and associated power differentials, so evident in society, are embedded in all human interactions and significantly in our individual psyches.17 Facing how each of us can perpetuate the problem requires not only insight and courage, but also solidarity and support. This is the only way that we will keep racial inequalities on the agenda beyond the glare of the pandemic and for long enough to make the sorts of changes Lawson4 calls for.
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2021
