Racial Trauma: The Burden of Being Black in Medicine

By Ashlea Winfield, MD, MSPH and Sanche Mabins, MD on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine

Trauma is any event, series of events, set of circumstances or environment that is experienced as harmful, having lasting effects on the individual’s functioning and well-being. While discussions of trauma and trauma informed care often center around adverse childhood experiences (ACEs), we often gloss over the disparate burden of trauma that is carried by individuals from historically marginalized ethnic and racial groups. Racial trauma or race based traumatic stress (RBTS) is mental and emotional injury caused by encounters with racial bias and ethnic discrimination, racism, and hate crimes. Through this article we aim to provide an awareness of race based trauma, highlighting a small fragment of the burden of racism within medicine and the associated cost.

“Can you refill the paper towels in the bathroom?”

Microaggressions as Every Day Racial Trauma

Imagine you are busy charting when someone interrupts to ask you to refill the paper towels in the bathroom. You look down at your embroidered scrubs and bright block lettered “DOCTOR” badge to wonder what made them think you were environmental staff. You know this perception that you are in a service position is largely because of your race, because you are Black. This is a microaggression.

Racial microaggressions specifically are “brief, everyday exchanges that send denigrating messages to people of color…” . While we frequently frame microaggressions as little annoyances, they are a form of racism that carries significant health burdens, affecting the mental and physical health of those who experience them. Microaggressions have been shown to lead to higher rates of depression, feelings of hopelessness, suicidal ideation, sleep disturbances, hypertension, and substance use

How others choose to respond to an individual’s experience of microaggressions may also alleviate or exacerbate trauma activation. Imagine talking to a faculty member or colleague to process a microaggression and they offer you an alternative theory that avoids discussions of race altogether. “It’s because you look so young.”

While we would like to think that this an atypical response, it has been demonstrated that dominant group members will often dismiss the notion of microaggressions or avoid discussion altogether, preferring to link the microaggression to another factor. Denying the role of racism in these instances leads to further invalidation and worsens traumatization.

The Cost of Foregoing Authenticity

A 2018 study published in JAMA highlighted the self-policing that minoritized residents must perform to be deemed professional. Many reported altering the way that they speak, wear their hair or other forms of selfexpression to meet more Eurocentric standards. The implications for this inability to be their authentic selves leads to increased psychological stress and feelings of not belonging, contributing to the phenomenon known as “imposter syndrome” which is nothing more than internalized racism rebranded to be a character fault of the minoritized individuals.

Racism in Evaluative Systems

Racism is pervasive within medical education, especially within our systems of evaluation and promotion. We use “objective measures” such as standardized tests that are associated with parental income and have repeatedly demonstrated racial bias. Within emergency medicine the standardized letter of evaluation (SLOE), perhaps one the most highly regarded components of a candidate’s emergency medicine residency application, lacks validity evidence and has also been shown to demonstrate racial biases. These measures then determine which fields of medicine a person is “fit” to enter, relegating trainees from historically marginalized to certain specialties, worsening depression, burnout, and attrition. The use of systems that perpetuate racism are not limited to residency but also serve to keep Black and Brown trainees from getting their feet through the well-guarded gate to a career in medicine.

Acknowledging Community Trauma

Community or collective trauma refers to “an aggregate of trauma experienced by community members or an event that impacts a few people but has structural and social traumatic consequences.” Community trauma disproportionately impacts historically marginalized communities that due to systemic racism and structural inequalities are more likely to be impacted by poverty, violence, and discrimination. As medicine has started to acknowledge the role of racism and social determinants of health more formally, there has also been increasing resistance from others who want to steer clear of “wokeness” within medicine by avoiding topics such as gun violence or the disproportionate murder of unarmed Black people by police.

The reality is that while many of our dominant group colleagues can go home and escape the realities of the outside world, individuals from historically marginalized groups cannot. Witnessing the trauma of others within our communities can lead to further traumatization. Studies have shown that after police killings of unarmed Black people, Black people within that state reported higher rates of poor mental health for up to three months. We also have to reckon with the violence perpetuated in our clinical spaces where we see members of our communities being denied life saving procedures at higher rates than whites and dying at disproportionate rates from preventable diseases. This trauma has also been compounded by the COVID-19 pandemic that ravaged Latinx and African American communities while political leaders blamed “colored people” for not washing their hands instead of acknowledging the impact of systemic racism. We are not learning and practicing in a vacuum and failure to acknowledge this will lead to further traumatization.

It is also very important to highlight historical trauma of the Black community due to chattel slavery, Jim Crow policies, and ongoing daily exposure to racism that has allowed trauma to alter the way in which our DNA is expressed and passed onto future generations.

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Dei Perspective

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“She’s Distracted on Shift…” How Does Trauma Show Up?

The usual rigor of residency is significant and compounding this with the additional burden of racial trauma may overload a trainee’s ability to cope. This constant activation due to the ongoing toxic stress can show up in many ways including but not limited to agitation and depression. Traumatized individuals may appear distracted or withdrawn on shift or may withdraw from medicine altogether. Once matched, Black residents are more likely to withdraw, be dismissed from programs, or take extended leaves of absence

Our inability to recruit and retain physicians of color is multifactorial, but we can be certain that a lack of awareness of the effects of trauma within medical education, specifically racial trauma, play a tremendous part. Medicine was not designed to be inclusive of minoritized groups, as evidenced by the hundreds of years of intentional exclusion from medical organizations such as the American Medical Association Medicine as it exists now has continued to uplift white supremacy as evidenced by the lack of physicians of color within medicine, recent overt racist comments on social media regarding the qualifications of a majority black residency class, and current attacks on affirmative action. To move forward and create safe, trauma responsive spaces, we must acknowledge that racism is weaved throughout the fabric of not only our country but also medicine. We must also acknowledge race-based trauma or we will continue to rob historically excluded trainees and faculty of safe environments in which to learn and practice.

While I have framed this discussion from my perspective as a Black woman, the concept of ethnic or racialized trauma applies to other historically marginalized groups including our Latinx colleagues and Indigenous Americans. I would also like to acknowledge the disparate burden of our LGBTQ+ colleagues, with special attention to our transgender and gender expansive communities who encounter trauma daily as our governing bodies strip away their rights to simply exist as their authentic selves

About The Authors

Dr. Winfield is an assistant professor of emergency medicine and the associate director of simulation at Cook County Health. She is co-chair of the ADIEM Mentorship Committee.

Dr. Mabins is a fourth-year resident at Cook County Health and co-leads the DEI subcommittee within the SAEM Education Committee.

About ADIEM

The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the goal of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”