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The ethos of medicine is born from rugged individualism. There was a man, his black bag, and his experience pitted against a cornucopia of ills and ailments affecting mankind. Essential to this approach is the perspective of the physician focused on the patient as a whole. As medicine was modernized in the 19th and 20th centuries, the knowledge base exploded. In addition, the physician workforce became more diverse and representative of the population. Thus, one person could no longer be the keeper of all knowledge, perspectives, and skills encompassed within the practice of medicine. Sub-specialists were born. This allowed more in-depth exploration of each facet of taking care of the sick, but an unintended consequence was the parsing or disaggregation of the patient into signs, symptoms, and diagnoses. Over time, the focus for each of the blind wise men feeling on the proverbial elephant degenerated into each describing the situation as a trunk, an ear, a belly or a tail. Thus, the reality that they were all describing the same animal was lost. Similarly, in medicine, as the pendulum swung further toward the extreme of subspecialty run care, the focus on the patient as a whole was sacrificed for an in-depth look solely at the list of things being treated.

The disaggregation of the patient led to some key realities affecting physician training, reimbursement for services rendered and the culture of medicine. In post-graduate medical education, physicians and surgeons no longer focused on common core knowledge. Every specialty focused on the ailments within their wheelhouse. The identity of disease consequences, beyond those strictly related to direct pathophysiology, took a back seat. This led to technical experts that sometimes lacked the compassion and comprehensive reasoning to see the impact of disease beyond the textbook and provide solutions that not only follow the algorithm but also were viable within the life construct of the one being treated. Reimbursement for services also changed. It moved from focusing on time and care to focusing on providing fees for “action” like a procedure or consultative service. Thus, being a generalist no longer garnered the billing and collections like sub-specialists. Narrow expertise was valued by the system in the form of higher rates of reimbursement and by the public in the form of a higher social cache and prestige. Finally, the culture of medicine changed through the disaggregation of the patient by subdividing the House of Medicine. The Orthopedic Surgeons could claim utter and complete ignorance on any matter affecting or concerning a non-musculoskeletal pathology – leaving an abused woman with a broken arm healed but not safe. At the same time, the Internist could move past the depression and social isolation caused by chronic and profound illness – leaving a diabetic patient labeled as non-compliant when they actually were just overwhelmed and sad at the realities of their life. This shift in how patients were seen had real consequences and not all of them positive.

To move the conversation from the esoteric and sentimental to that which is more concrete and practical, one must acknowledge how much this change has increased cost in the system. The increases come in part from an expanded number of providers per patient, a lack of efficiency in the system and competing priorities of the sub-specialists. Historically, a newly diagnosed middle-aged, type 2 diabetic would be treated and seen by the town generalist. That physician would talk about the disease impact, manage the patient response to being diagnosed with a chronic illness, and prescribe medication and dietary interventions to prevent morbidity and mortality. This changed in a subspecialist driven approach. The patient would be parsed and treated by the primary physician for general matters, an endocrinologist for diabetes, a psychiatrist for the adjustment issues related to the diagnosis, and countless clinical specialists to train the patient on dietary changes, medication administration, and compliance. Thus, the professional service charges for care go from an office visit and extended time for counseling by one physician to three sets of physician professional fees, and numerous covered encounters with other clinical professionals. In addition to the absolute cost of having multiple doctors involved, there are indirect costs from decreased efficiency having multiple treating providers. Laboratory work to monitor disease management in a diabetic patient is a common area of service duplication. Labs could be ordered by the primary doctor and repeated by the endocrinologist. And, done a third time if the psychiatrist seeks to start a medication with a metabolic side effect. The system paid for three sets of labs when one would have sufficed. Lastly, there is a cost in one specialist prescribing an intervention that improves the patient from their perspective while destabilizing them from the perspective of another specialist. The endocrinologist is focused on keeping the blood sugar under the best possible control in diabetics. If glipizide is a part of the treatment prescription, it may cause a rash or hives. These skin changes can then cause the patient distress about their appearance. This distress then leads to social isolation and symptoms of depression. Those changes cause the psychiatrist involved to increase interventions and medications. Having multiple unconnected providers can drive costs upward as the action of one provider can cause an increase in services by another. The cost increase affects patients, individual physicians, non-physician health care providers, hospitals, and healthcare systems.

In spite of the tremendous clinical triumphs of the era of modern medicine, there has been a negative effect of patient disaggregation. In turn, some of the earliest and easiest reform efforts have focused on restoring the sanctity of the whole patient unit. In medical education, there has been a return to core competencies required of all medical and surgical specialties in addition to the sub-specialty knowledge and skills required. This helps the former rugged individualists realize their place on the team of providers focused on helping patients live healthy and full lives. Reimbursement now incorporates outcome and quality measures that take into account more than just how complex and procedure-oriented the intervention. Reimbursement is also restoring some parity between rates for generalists and specialists as evidenced by the increase in reimbursement rates for initial and follow up evaluation and elimination of consultation codes. These reimbursement changes can make a difference in how medical students select a career path by allowing generalists and subspecialists to be normalized in revenue generation compared to one another. And, finally, the culture of medicine is returning to a point that prioritizes patient-centered care to the same degree as evidence-based medicine. All realize that humpty dumpty has fallen, or was pushed, from the wall and shattered into pieces. Each specialist was happy to select and care for their piece without care for how those pieces were going to reunite the whole. The next iteration of medicine will combine the advances possible through the successes of modern medicine with the good, old-fashioned efficacy of a complete and comprehensive patient-doctor relationship.

Many in white America have had the privilege of only considering or being forced to think about race in isolated spurts. The concept that there may be a different, yet valid, set of perspectives and experiences based on the color of one’s skin seems uncomfortable. Thus, it is tacitly avoided and ignored.   That option is not there for me as a black man. I do not have the luxury of acknowledging race sporadically and occasionally. It is omnipresent and impacts many aspects of life in small and large ways. The duality that white America only considers race when forced and people of color navigate it daily is the foundation of why reconciliation and “progress” on the subject is such a challenge.   When confronted with various societal situations, many whites feel race is “injected” into places where it is irrelevant or not germane. In contrast, what I see is race being dismissed and ignored although it seems obvious and impactful; even when there are other factors also at play. Gone are the days when my work as a physician is a respite from societal ills.   I have learned as a Pediatric Rehabilitation Medicine doctor, delivering difficult news to people that do not want to hear it, empathy goes a long way.   Thus, I need all considering the impact of race in American society, the House of Medicine, and the patients we serve, to start with a recognition that this process will require one to empathize with concepts that may seem foreign and outside of your experiences or those of your peer/family group.

When I present to a family that their child was able to survive a harrowing near-death experience, but will be left with durable and significant physical/mental/cognitive disabilities, empathy from me is required. I use my knowledge of medicine and my experience to inform the information I bring to the table for discussion. However, it is critical that I appreciate the life experiences, cultural context and previous experience with health care that the family brings to the discussion. For me to be effective, I must accept that the family “is where they are” and their experiences are valid on face.   Similarly, when there is a conversation about race and its negative impact on the lives of people of color, it is necessary that white America come with their perspective, but be willing to accept, on face, the validity of the collective experiences of people of color. The conversation is over before it begins when a person in the majority class tells someone that they must be wrong about what they experienced, misunderstood what really happened in the experience, or did not rationally consider all the aspects of what they experienced. In short, when a person of color relates their experience, believe them rather than debate them. Once we start the conversation about race there is one additional expectation. People of color must realize that those in the majority may have never considered this topic in detail prior to engagement. To use a clinical example, I have to know that parents are by and large doing their best to make good decisions for their children in times of crisis. And, although I spent years thinking about and managing catastrophic disability in children, my consultation may be the first time these parents have thought about disability in general, let alone in their kids. Both parties do different things to engage and be ready to find consensus.

As a black physician, I regularly encounter children and parents that have rarely interacted with people of color, or never done so in the context of the non-white person being in a position of authority. Conversely, patients of color rarely see a physician that “looks like them”. Thus, race can be a barrier to establishing a close patient-doctor relationship.   Race is not something that is “transcended” by black healthcare professionals. And race co-localizes with culture in shaping communication styles. One cannot “opt out” of acknowledging race and its impact on the House of Medicine by stating that such sordid things are beneath our professionalism. To do so would be to ignore the history of segregation of medical education. It would also ignore the social science data that unconscious bias negatively impacts patient outcomes. Finally, ignoring that race has an impact roundly dismisses the “why” behind why there are fewer black males choosing to go to medical school in 2016 than in the 1970’s in spite of a growth in the number of black male graduates from college that would ultimately be eligible. Implicit or explicit assertions that communicate, “I don’t see color”, actually communicate an unwillingness to notice or acknowledge that there are those that look, live and experience a life different than that of the majority culture.

A large body of data has demonstrated that there are significant and profound health disparities. These disparities are multifactorial, but institutional bias and unconscious bias are a portion of the problem. If people of color are marginalized, their experiences deemed implausible or invalid, it is unlikely that the system providing them care will result in the best outcomes. It is very difficult to describe the objective difference between being “talked to” versus “talked at”. However, if one is experiencing that reality it feels quite clear.   Too often the impact of race on patient access, patient experience, and patient outcomes are justified using socio-economic rationale. The differential impact is also minimized by lumping the data from people of color into a larger majority population that dilutes the findings. Again, I rely on my experience as a Pediatric Rehabilitation Medicine doctor for perspective. Just because our able-bodied children can come into a clinic setting unfettered and with satisfaction does not mean our children with disabilities will not find that same clinic difficult to enter and exit. It would be easy to dismiss the experiences of our patients with disabilities in that clinic setting as “not representative of the whole population” or “something they seem overly sensitive to”. But, the more just an equitable approach acknowledges that minority populations may need different things from the clinical setting for that place to be optimal. And, optimal settings contribute to eliminating health care disparities. As uncomfortable as it may be, race can negatively impact our patients. As health care professionals we are part of the team that is tasked with doing something to change that situation. We are responsible for that change whether the barriers are things created within our clinical setting or metastasize from larger community upheaval as is evident currently around situations in St Paul, MN, Baton Rouge, LA, Dallas, TX, and countless other locations.

A large challenge to “fixing” issues related to race is that the work of change has been left to the oppressed to end their oppression. That has to evolve, and not just for symbolic reasons.   Children that come see me for physical rehabilitation services have a responsibility to advocate for, express and set goals for their lives. However, I as their physician must be in active partnership with them for results to be optimal. It is not the role of a disabled child to manage their disability and all of its consequences with no help from me as a person of influence, experience, and privilege.   Similarly, people of color need white allies to usher in change. Once white America agrees that issues affecting people of color are unjust and stand for that in a strong majority, the tensions we are experiencing as a country will dissipate as the root causes will have a strong impetus to be changed. Even the most progressive and empathetic members of the racial majority consistently report feeling overwhelmed and helpless when they get a glimpse of the enormity of the problems that are culminating invisible and raw racial tension. I encourage those that seek to be allies to help translate what you appreciate about the challenges facing people of color into a language that your less convinced peers can appreciate and understand.   Educate yourselves about what has been done and is actively being pursued by advocates for social justice. Do not rely on your “one friend of color” to be your personal tutor on the subject. History is at your fingertips. See where you can find a place to lend your energy for change. Lastly, avoid the temptation of being the “Tarzan” saving all the masses of “darkies” unable to achieve their salvation without your divine providence.   Be a real person, an empathetic person, learning and growing with folks that genuinely want a society that demonstrates that its Black Lives (actually) Matter.

These are tough times. It is not that race and its stifling and exhaustive effects were not there in the past. The reality is now our society is reaching a tipping point where those that had no or limited voice are demanding their place at the table.   The reality is that transgressions that happened in silence and were explained away as a fallacy is now laid bare via social media and technology.   The reality is although America has elected a black man as president and values Jazz, Hip Hop, athletics and cultural touchstones that originate in the Black Community, that society devalues black men, women, and children in ways large and small consistently.   As a black man, it is easy to become embittered, withdrawn and resigned to the reality that you will be seen and judged by things beyond your control.   But, I choose to do what I can to give myself the best chance of impacting those that need to do right by me and those that look like me. I choose to stand in my truth and humanity rather than beg anyone to recognize my right not to be harassed or killed by those supposedly created to protect and serve me. I choose to balance my rage with the optimism that today we start finding solutions that make tomorrow better than yesterday. I choose to not be broken by the fact that that my pair of terminal degrees from one of the most storied institutions in the country, my access to good credit, my solid and substantial economic opportunity, nor my supportive and nurturing family cannot save me from being one bad traffic stop away from being the next trending hashtag.

Who I do not cease to be because of what I do.   I am an empathetic and connected physician that cares for some of the most vulnerable children in our communities. Those skills were informed by what it took for me, as a first generation physician and the first black male to be board certified in my specialty, to make a way where no path previously existed.   Now, it is time for my career to use what we know how to do in optimizing the human side of medicine to optimize the raw pain that is left with a four-year-old St. Paul girl, who witnessed the killing of her father figure in front of her mother at the hands of the Police. We must use our skills as health professionals to be a balm that soothes a sobbing Baton Rouge teenager that just “wants [his] daddy”. We must use our skills as empathetic healers to hold that girl and that boy, and all those hurting just like them, and say “its ok, I’m right here with you”.