Abraar Karan: How do we deal with “old guard” bigotry in healthcare?

The way we respond to the so called “old guard” as social and cultural norms begin to outpace their ways of thinking is an important and complex topic, says Abraar Karan

abraarWhat do we make of older clinical professors and doctors—some who are world experts in biology, physics, chemistry, medicine, and more—who were brought up with very different social norms, and who hold outdated notions of human rights, health equity, racism, sexism, and other exclusionary ideologies? Should they still be allowed to keep their positions, especially if they’re eminent ones? Whose job is it to “re-educate” them, if anybody’s? 

This is a problem that every single one of us has likely dealt with, if nowhere else than in our own home. For many people, grandparents and others of their generation may well hold views that we socially disagree with. That doesn’t mean we disrespect or disregard them as human beings, but their words can still carry weight and be hurtful. When the people holding these views are placed in a position of power, such as in front of a classroom, or in front of a patient, then what? Does this in some way endorse them, or falsely legitimise them? I’ve had many such experiences with senior doctors who are near the end of their careers. They have immense wisdom, and incredible clinical lessons to teach, but at times can have socially antiquated views that may be unintentionally harmful to patients, nurses, and trainees. 

In an incident I remember particularly well, I was in a medical lecture in which the speaker made remarks that were both sexist and racist without even realising that he had. What complicated the speaker’s offensiveness was that he was from a much older generation, and it didn’t seem that he had intended any harm. His age alone certainly did not justify his words, but it did make it easier to understand where they may have come from. The overall message of his talk, which was focused around themes of person centred care, was certainly noble. 

Afterwards, a debate among the audience members, who were largely much younger, ensued. Some people wanted the speaker permanently removed from any kind of teaching role. They did not believe his views had any place in medical education. His age, they concluded, was not an excuse and his words certainly were still his responsibility. The other half was more forgiving. They felt that given we could recognise his unintentional mistakes and outdated ways of thinking, that we could choose to absorb the good that he offered and ignore the bad. Moreover, for his era, he was relatively progressive—just not so much for ours. For this group, intention seemed to matter more than what was actually being said. 

But to what extent can intention be used to defend what is otherwise wrong? I recall once taking care of a patient in the hospital who was experiencing hospital-induced delirium. This patient did not know where they were or what year it was—but made no mistake in calling a black nurse by a derogatory word multiple times during their stay. We were all quite confused as to what to do. If this patient was well and had all their usual faculties, we would have made a behavioural contract which, if violated, could result in them being transferred to a different hospital. But given the patient’s lack of mental capacity, we couldn’t do much but apologise and support our colleague. I often wonder about this case, because even if the patient didn’t entirely know what they were saying, they knew enough to formulate hateful thoughts and words. And so, while we didn’t know their intentions, we certainly couldn’t rule out that they may have been malicious.   

How do we respond?

The way we respond to the so called “old guard” as social and cultural norms begin to outpace their ways of thinking is an important and complex topic. Some acts of opposition have already begun to take place. Earlier last year, for example, the portraits of past, largely white male department heads at my hospital were removed from the main auditorium. It was a move that was meant to symbolise a dismantling of legacies tainted by racism and sexism, yet it also resulted in significant pushback, including from the former dean of Harvard Medical School, Jeffrey Flier. In an op-ed, he suggested that a more useful approach would have been to have a rotating set of new and old portraits to contextualise the complex struggle for equity while not erasing the past. 

In a similar vein, former president Barack Obama recently commented during his foundation’s annual summit that today’s “woke” culture, which is driving forward liberal ideologies, runs the risk of conflating change making with being judgmental. He said that, “The world is messy, there are ambiguities. People who do really good stuff have flaws.” 

I feel that nuance, as with everything, is critical here. One might argue that our teachers and senior doctors with antiquated views are products of the societies in which they were born—a decision which was not their own. Some of them may have even been seen as quite “woke” during their day. It does not exculpate them in full, however, largely because there are so many from those generations who don’t hold such views. Furthermore, the repercussions of what’s been said and done depend on the degree of offense or harm they’ve caused—as with everything, there is a spectrum.

I have immense respect for many of the mentors I’ve had who were from an older generation and who I knew held social views that are very different from my own. I have learnt so much from them about how to care for patients, about physiology and biology, about how to take a good history, and perform a thorough physical exam. In no way do I support their outdated views—and will be clear in saying that these views perpetuate forces that harm and kill minority groups. 

What do we do about this? Removing them from their positions is unlikely to solve the larger problem, even if it could rearrange power in the short term. It could also cause others in power to hide their views, the result of which is often microaggressions, which are more subtle but still dangerous manifestations of oppression and exclusion. 

Open dialogue—including calling out harm when one sees it—is an important first step, but is challenging because those who’ve been harmed are too often expected to bear the responsibility for speaking up, and are potentially vulnerable to repercussions if they push back. There has been notable research on the effects of diversity and inclusion training within organisations, which has uncovered some interestings findings. A recent paper in the Proceedings of the National Academy of Sciences, for example, suggested that these programmes could reduce sexist views, but did little to actually change behaviour

While the onus should be on our leaders in hospitals, universities, public health schools etc. to regulate how much power people with these views hold and how much educational privilege they have, the reality is that some of our leaders may very well hold these views too. Unfortunately, I don’t have the answers, but I hope these thoughts spur further reflections and suggestions.

I suspect that in the decades to come, future generations will think of us the same way. They will likely look at things we have said and done today with similar disdain, as they probably should. That is how we become more thoughtful, critical, and just as a society—how we get better and do better by those who are most harmed by the status quo. I only hope then, in that future, that the generations who look back at me and my own work do so with a firm commitment to this: that what is right is right, no matter if no one is doing it; and what is wrong is wrong, even if everyone is doing it. 

Abraar Karan is a doctor at Brigham and Women’s Hospital and Harvard Medical School. Twitter @AbraarKaran

Competing interests: None declared.

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.