“Abraar, Ahmed … it’s all the same.”
My medical school professor said this as he flipped through charts of patients we would see in his afternoon clinic. I was a fourth-year medical student assigned to work with him, and he had apparently misheard me say my name as “Ahmed.” (It’s Abraar.) Rather than acknowledge my attempt to correct him, he made a racist, dismissive remark.
In that moment, I felt like I couldn't do anything. He would be writing my evaluation, and I could choose to either brush it off, or to risk hurting my career. I remember feeling angry and embarrassed. His comment felt like an attempt reduce me to just another brown face in a white coat. If this had been a chance encounter on the street rather than in the hospital, I wouldn’t have hesitated to call him out for his ignorance. Instead, I laughed it off and we finished seeing patients that afternoon.
Near the end of 2019, the New England Journal of Medicine published yet another study on the prevalence of abuse among medical residents in the United States. In this study, the authors report data from all 262 general surgical residency programs in the country. Nearly 1 in 3 residents reported gender-related abuse, physical abuse and/or verbal abuse. Nearly 17% reported racial discrimination, and 10.3% reported sexual harassment, although this latter number nearly doubled among female respondents.
[It] felt like an attempt reduce me to just another brown face in a white coat.
While the results should be astounding, any doctor can tell you they are not. In fact, what you’ll likely hear from older doctors is what we in the new guard have heard hundreds of times: “It was worse in my day.”
I was subjected to racist and discriminatory remarks in medical school multiple times. On another occasion, a department head I had been shadowing in clinic announced, in front of a patient and me, that Islam was to blame for terrorism. I remember how the patient looked nervously at me, confused that the doctor would say this during her medical appointment. I was unsure if he was directing these comments at me (part of my family is Muslim, although I am agnostic), or how he expected me to respond. I said nothing.
I should have been in a position, more than many medical students, to do something about these offenses. I was the president of my medical school class, and I had helped create policies and systems designed to stop this kind of abuse. However, I knew these issues were far more complicated than creating stricter policies or having one colleague reprimand another.
At our medical school, the system for dealing with these types of issues required anonymity, supposedly to protect the student, and I worried that in discussing the specifics, the complaint would surely be traced back to me. In both instances, I believed the doctors knew that what they were doing was wrong. But I wasn’t convinced that they would change their behavior, unless they were scared of serious recourse, like being fired.
What is interesting and deserves attention from the NEJM study is that there were a handful of programs with reportedly very low levels of mistreatment. To follow this up, the SECOND trial will be randomizing surgical residency programs to an intervention arm that includes a “Surgical Culture Toolkit”, in-person meetings for residents and a coaching component to see if these types of measures can make a difference. The study is also doing further analysis to understand why some programs have much lower rates of mistreatment than others. The results will be important and informative, but I believe that at the heart of all this lies an issue of accountability.
I knew these issues were far more complicated than creating stricter policies or having one colleague reprimand another.
Medicine continues to be plagued by an “Old Boys’ Club” culture. Those who abuse power are protected by colleagues, institutions, titles, money, privilege and more. Pervasive between the lines of medical education is the “hidden curriculum” or “the way things are done around here.” Medical students are quickly swept into it, largely because their future residency placement depends on them adapting, being liked by their team, and not making things too difficult so they can get good evaluations. But sometimes, the difficult thing to do is also the right thing to do.
Perhaps I should have said something to my professors in those moments, or found a way to make sure that they didn’t do this again to other students. The reality was that both professors were leading figures in their fields, and in the hierarchy of power, I was a relative nobody. I remember doing the cold calculus in my head: If I did speak out, what if one of them made up something about me in retaliation, or wrote negative remarks about my clinical acumen? What if they claimed that I misunderstood them, or that they never said that? Then what? I feared I would not have matched to my desired training program, or that I would get stuck with a negative reputation as a complainer.
As I become more senior in my field, these types of mistreatments become easier to handle. Movements like Time’s Up Healthcare are shifting power dynamics and flattening the hierarchies that birth and perpetuate abuse in the hospital. If a senior fellow or attending is rude or dismissive, I can stand up to them more easily. My clinical competency is harder to dismiss or attack now — I have proven that already through multiple years on the wards.
Nonetheless, the hierarchy is far from gone, as is the abuse. In the future, I still have to apply for jobs, make my way through a long and competitive promotions ladder and eventually, establish my career. It’s quite likely that I’ll encounter mistreatment again. Do I laugh it off? Or stand up against it, with all the strain and complexity that entails, and hope for the best?
Trust that the choice is much harder when your future is on the line — even when you know the right thing to do.