Blog by Rachelle Ann Gonzales, BS*, Alex Im, BS* and Cynthia Romero, MD
*Corresponding first-authors
During the early days of the COVID-19 pandemic in the United States, I vividly remember watching a viral video of a young man attacking a masked, middle-aged Asian woman at the Grand Street subway station in New York City. I looked with horror as the man charged, unprovoked, fists flailing while screaming “Diseased! Diseased!” This disturbing event and subsequent reports heralded an unsettling realization that I, a Korean-American, could be next.
A few months later, an attending inquired where I was from. “Corona, California,” I replied. He offhandedly asked, “Do you eat bats — are you from Wuhan?” I immediately froze. The next day, a different attending asked where I was from. I mumbled, “Southern California,” before the resident from the previous day prompted the attending to ask which city I was from, specifically joking that I was trying to hide it.
Although these two events spanned about only 20 seconds, I was left with a sense of reverberating uneasiness: a few months ago, I feared bodily harm. Instead, I found myself assaulted with piercing racial remarks and attitudes. The attending implicitly demonstrated that it is fun to be racist and is acceptable to teach other doctors that behavior. [A.I.]
The history of Asian-American discrimination is a tragically long story of bias—yet the bias virus continues to spread, and medical education has not been immune to this pathology.
At the same clinical facility where Alex experienced discrimination, I, a Filipina-American, was often mixed up with two of my classmates, one of Chinese descent and the other of Guamanian and Italian descent. We initially laughed it off because we were all wearing masks, and one time we stood side-by-side to distinguish ourselves to the involved hospital personnel. As the rotation progressed, the confusions persisted: during my patient presentations, I was called by my Guamanian classmate’s name, my Guamanian classmate was called my name while on the patient floors, and my Chinese classmate received feedback for research I had done the day before. We lost count how many times we were mixed up, despite our respectful corrections at each occurrence.
The nurse practitioner (NP), who had worked at this location and advocates for medical students, noted that anti-Asian microaggressions have been made toward Asian students and hospital staff in previous rotations. Despite the NP’s offering to speak up for those involved, these incidents were not reported due to student and staff concerns about “rocking the boat.” This mind-set is a common stereotype of Asian Americans.1
However, my classmates and I wanted to make change and brought our concern to our associate dean for clinical education, who reached out to the directors of the clinical site. Unbeknownst to my classmates and me, the directors asked the chief residents at the site to meet with us the next day to address our concerns. The next day, one of the chief residents walked into the work room and pointed at me and my two other classmates and said “I’m looking for people of Asian descent. You all are in trouble.” Although the direction was for the chief resident to address our concerns, the behavior of our “teacher” implicitly “taught” the students in the room that speaking up will result in retaliation rather than a solution. [R.L.G.]
Our stories, unfortunately, are not unique. Between the 1882 Chinese Exclusion Act and the Immigration Act of 1924, the United States first banned Chinese people and then all Asians from immigration — and the burdens of being an “interchangeable Asian” persist to this day.2 Indeed, violence has been amplified during the COVID-19 pandemic by hateful, anti-Asian rhetoric from the former president and others who deliberately and repeatedly mischaracterized COVID-19 as the “Wuhan Virus,” “Asian Flu,” “Kung Flu,” “Chinese Virus,” and so on.3
In response to both our situations, our medical school advocated for us well—a different resident was assigned to perform our evaluations, and the involved individuals at the medical facility participated in professionalism meetings and implicit bias training. Still, the involved individuals’ response to our concerns was disheartening: “Everyone is wearing masks, so anyone can get mixed up.” A study of Asian medical resident experiences across three different institutions revealed that 99% of respondents were confused with team members of the same race/ethnicity at least once within the past year.4 Further, Asian Americans still labor under the myth of the model minority—“Asian Americans work hard and are successful despite racial discrimination”—that condones and normalizes aggressions.5
The fundamental issue is implicit, abiding, and unquestioned bias: for example, our medical school was disrupted in 2019 after a discovery that Ralph Northam, previous Virginia governor and our medical school alumnus, was pictured in the school’s yearbook in blackface in a Ku Klux Klan context. Our school acknowledged its history in the complex circumstances of racism, adopted the Live Humble Quality Enhancement Plan focusing on cultural humility for an increasingly diverse world of practice, and formed a Community Advisory Board for Diversity and Inclusion, among other initiatives.
Useful first steps in fighting the bias virus involve empowering medical students to report and discuss mistreatment without fears about retaliation.6 For instance, our medical school provided resources for reporting mistreatment, took steps to protect us and our academic evaluations from the individuals involved, and applauded us for speaking up. Our medical school has URM representation among leadership and faculty—originally indicating “underrepresented minority,” the term now refers to “underrepresented in medicine.”7 In fact, URM representation among our medical school’s faculty facilitated efforts by one of the authors to establish the Filipin@ American Medicine group to combat Filipinx-specific health disparities.
Another constructive step could involve medical students taking the Implicit Association Test during their preclinical years.8 Graduate medical education that includes instruction about implicit bias, particularly with respect to clinical decision-making, may sensitize physicians and improve their skills.9 Implementing the Implicit Association Test and similar instruments also instills greater cultural humility during patient care and medical education.
The ongoing pandemic has raised understandable fears about the novel virus, but it has revitalized the virus of bias that spreads and works in subtle, insidiously destructive ways. This virus will not succumb to a vaccine, but, with continued collective dialogue, education, learned humility, and protective systems, we may yet stop passing the bias virus.
Rachelle Ann Gonzales is a Filipina-American, Southern California native who is a 4th-year medical student at Eastern Virginia Medical School. She is pursuing the Family Medicine specialty and is passionate about underserved medicine, mentorship, medical education, and advocacy.
Alex Im is a Korean-American, Southern California native who is a 4th-year medical student at Eastern Virginia Medical School.
Dr. Cynthia Romero is an Associate Professor in Family and Community Medicine and Director of the M. Foscue Brock Institute for Community and Global Health at EVMS. She is a former Virginia State Health Commissioner and past president of the Medical Society of Virginia and Philippine Medical Association of Southeastern Virginia.
Works Cited
[1] Kao AC. Invisibility of anti-Asian racism. AMA J Ethics. 2021;23(7):E507–E511.
[2] Chen BX. The cost of being an “interchangeable Asian.” The New York Times. June 6, 2021:BU1,6–7.
[3] Jun S, Wu J. Words that hurt: leaders’ anti-Asian communication and employee outcomes. J Appl Psychol. 2021;106(2):169–184.
[4] de Bourmont SS, Burra A, Nouri SS, et al. Resident physician experiences with and responses to biased patients. JAMA Netw Open. 2020;3(11):e2021769.
[5] Tran N, Yabes K, Miller A. How should clinicians help patients navigate “model minority” demands? AMA J Ethics. 2021;23(6):E456–E464.
[6] Dwyer J, Faber-Langendoen K. Speaking up: an ethical action exercise. Acad Med. 2018;93(4):602–605.
[7] Association of American Medical Colleges. Underrepresented in medicine definition. March 19, 2004. Accessed August 6, 2021. https://www.aamc.org/what-we-do/equity-diversity-inclusion/underrepresented-in-medicine
[8] Motzkus C, Wells RJ, Wang X, et al. Pre-clinical medical student reflections on implicit bias: implications for learning and teaching. PLOS One. 2019;14(11):e0225058. doi:10.1371/journal.pone.0225058
[9] Schwappach DLB, Gehring K. Trade-offs between voice and silence: a qualitative exploration of oncology staff’s decisions to speak up about safety concerns. BMC Health Serv Res. 2014;14:303.