Arundhati Dhara is an Assistant Professor at Dalhousie University in the Department of Family Medicine
Saroo Sharda is an Anesthesiologist in Oakville and an Assistant Clinical Professor at McMaster University
There are few data available on the racial make-up of Canadian female physicians. What data exist suggests that South Asian and East Asian groups are over-represented relative to their proportion of the general population and Black and Indigenous people remain underrepresented.
There is also evidence that non-white physicians experience discrimination from colleagues and patients ranging from daily microaggressions to more overt acts. While organizational anti-discrimination policies often exist, we are generally ill-prepared to deal with incidents when they occur and in their immediate aftermath. The clinicians experiencing bias are often left to act, and must weigh power dynamics against speaking up. The damaging effects of physician discrimination based on race or gender are clear, and yet we know little about the ways in which gender and race intersect to further marginalize women physicians of colour.
Kimberle Crenshaw, a black feminist scholar, first coined the term “intersectionality’ in 1989 as a way to describe the ways that sexism and racism act synergistically against black and brown women. She noted specifically that insistence on considering the two separately is a strategy that can be used to silence or dismiss the experiences of black women. When considering sexism in Medicine we have largely taken the experience of women as universal and, as such, we have rendered racialization of women physicians invisible.
Obviously, participating in conversations about race is challenging and can bring up discomfort for us all. So how can we empower physicians to engage in what can feel like a powder-keg of misunderstanding? Clearly there needs to be a multi-pronged approach. Training programs and institutions must invest in and take responsibility for the development and delivery of evidence informed programs. However, personal reflection is also important – there are ways that we as individuals can learn to approach our peers in conversations about race.
There are unspoken rules about racism, and one is that we don’t talk about it. When we do, people often shut down. However staying open during these conversations is critical to making change. In training we are taught that a carefully taken history will lead to the diagnosis 80% of the time. What we don’t learn is that in order to listen well we must, for lack of a better term, “check our privilege”. For racially privileged women in medicine to acknowledge that their racialized colleagues face discrimination – that they may themselves be perpetuating – disrupts the idea of female solidarity and community that we tell ourselves we hold. Often, we aren’t even aware that this is happening because of the implicit bias we all experience.
Satyantani Dasgupta, a physician and medical education scholar, calls on us to listen with what she terms narrative humility .
“Taking a position of narrative humility means understanding that stories are relationships we can approach and engage with while simultaneously remaining open to their ambiguity and contradiction and while engaging in constant self- evaluation and self-critique about issues such as our own role in the story as listeners, our expectations of the story, our responsibilities to the story, and our ownership of the story”
What if we extend the concept of narrative humility from interactions with patients to conversations with our marginalized colleagues? We have found that keeping the idea of narrative humility in mind is helpful in moving beyond feelings of awkwardness and defensiveness when entering conversations about discrimination.
As a way to operationalize engagement we offer the following suggestions, balancing our desire to do good with our inevitable participation in a marginalizing system.
- Consider who has the moral authority to speak and who has the moral obligation to listen. Centre the experiences of those who have been marginalized or silenced. They have important knowledge to share, if they are able. Understand that they may not feel safe speaking up.
- ‘Check’ your privilege. We must examine our implicit biases and consider our personal experiences of privilege and how they relate to the marginalization of others, no matter how uncomfortable.
- Listen with Empathy. Medical training emphasizes careful listening and the extension of empathy to our patients. Offer the same empathy to colleagues who may be in a difficult or vulnerable position.
First of all, I would like to sincerely thank you for this exchange, because it has allowed me to critically develop my own position, and to better understand yours. This is a long comment, but it will also be my last.
Miraculously, for reasons that we must seek in the anecdotes of real history, liberal democratic society emerged – in part in Europe, but most decisively in the New World – of which the crucial defining element is the liberty and equality of individual human beings : that All Men Are Created Equal.
This principle has remained constant through the last 240 years, and as it became admitted that people of other races (and women, also), were indeed men (for the purposes of this definition), full legal status has in fact become available to all people.
Today, a woman in Canada, of any color, raised in any tradition, can effectively declare her independence (should that be required), by getting a job and removing herself from whatever situation might have been limiting her. She can, also, access publicly funded resources in doing so.
Therefore, in a rational evaluation of the barriers faced by women, white privilege would seem to be a trivial factor in comparison to the influence of non-racially specific learned tradition. Moreover, white privilege, expressed in the politically dominant choices of those wielding that privilege, is precisely what allows women (and men) to escape from both the formally oppressive structures found in many other lands, as well the ad hoc, informal, oppression, frequently found in the home.
But the proof, as they say, is in the pudding. You mention that the medical profession has only been open to women for one century. And yet now, 54 % of physicians under forty are women, as are 58 % of first year med students ( https://healthydebate.ca/2018/10/topic/gender-wage-gap-medicine ) .
That is definitely amazing change, which represents (as you note) thousands of years of prejudice and tradition (largely) overcome in just one hundred years. And the situation regarding racial tolerance in Canada is just as miraculous.
In my first comment, I believe I stated, that from this amazingly positive starting point — and given the obvious good will that is constantly being demonstrated by the privileged class (as evidenced by your own, fully typical, reflex to champion perceived victims of injustice) – it might take another two or three generations to finish the job. However, my main point was, this : that a structural societal crucible HAS in fact been created in which the transformations which we all desire are actually occurring, and at a rate faster than anybody could have believed possible.
And yet we constantly encounter the following argument from those who are somewhat new to adult life and responsibility : Just because it is better, than anything else that has ever gone before, that does not mean it cannot be better still.
To which I reply : You are right. It can and it will. Just be sure that you remember what it is we are trying to do here, and that YOU maintain the conditions required for success.
Because, unfortunately, it is those conditions which are currently under attack. The operating principle that destroyed slavery (and allowed women the right to vote and possess property), is, to repeat the essential meaning of our society : that ALL MEN are equal. And yet we are now under extreme pressure to change that principle ; to organize our goals, not in terms of individuals, but of collective groups ; and to argue about the “moral authority” of those groups. This is, to put it timidly, a recipe for disaster.
The most destructive force in human history is the collective pitting of human beings against one another ; and the most motivating power that can sustain individual human beings in such struggles (above even simple self-preservation which can lead us, rather, to submission or flight) , is a deep belief in the justice of our cause. But we are now raising a generation of altruistic youth (yet another) who are unconditionally dedicated to the correction of collective wrong. Who are, that is, ideally committed to fight, at a time where there is, objectively, nothing (collective) to fight about.
The numbers are irrefutable : in this generation the allegedly oppressed group, that is POC (or everything other than white), is going to inherit (not seize, not win, not gain, but simply receive) political ascendancy through numerical majority in a democratic state (something else that has never happened before).
The only thing on our minds now, therefore, should be to ensure that this inevitable transfer occurs peacefully, in the respect of basic individual rights historically gained, and with a minimum of collective resentment.
Unfortunately, though, Victim/Identity/Oppression is all about resentment. It is not only about equality : it is also about getting even. Examples of policy initiatives, already floating, include reparations for slavery and compensation for indigenous lands ; there is, understandably a corresponding sense of foreboding, gradually permeating public consciousness beyond the political class, regarding the manner in which those terms will eventually be defined. And because of the trans-sectional nature of opposition politics, we will surely have to deal, at the same time, with economic policy drawn from poorly conceived re-writes of Das Kapital.
But without question, the most dangerous prospect, is that some significant portion of the “white population” (whatever that actually means) will, themselves, increasingly adopt the language and tactics of identity politics. This is not merely speculative : over 60% percent of white men (and 54% percent of white women) voted for President Trump in 2016. Yet should that seem menacing, let us remember that fully 90% of African Americans, have voted for only one party over the last fifty years.
My personal conclusion, is, that the only way to avoid possibly catastrophic outcomes (imagine serious social breakdown in a place as cold as this), is for people of good faith, on both sides of these issues, to minimize the collective dimension, and to maximise respect for the individual, whatever his (or her) identifying characteristics.
Thank you the the feedback on my post. And thank you for the link. I listened to the webinar yesterday (Racism and Privilege in the Everyday).
I agree that all voices are not heard equally. Humans are bad at listening (this comes from Ralph G Nichols who made the study of listening his life’s work). Of course we see examples of this all the time. I work at listening well, but I am most certainly flawed. That said, using ‘moral authority’ to determine who can speak seems to me as a form of censorship. I don’t see how this will help in the exchange of ideas. Censorship and in this circumstance, self-censorship are very dangerous.
I have one link to recommend. It does not address ‘moral authority’ directly but it does speak to many of the issues related to the article we’ve been discussing.
Jonathan Haidt: The Three Terrible Ideas Weakening Gen Z and Damaging Universities and Democracies
Gordon, if that is a genuine question re: the definitions of these terms, then I would like to respond in a genuine way (and will not belabour my point further).
I believe firmly that it is incumbent on me to understand how implicit, chronic prejudice plays itself out in our 21st century Canada, and although I am certainly no expert, I have done much to educate myself. I have not always embraced this journey wholeheartedly, but I am learning to humbly recognize my own privilege as a white, settler Canadian, and listen open-heartedly to the experiences of others.
One series that has served to greatly educate me on this journey is the Indigenous cultural safety webinar (one resource I have used of many, but truly an excellent one). I have copied it below. It discusses over many series the chronic legacy of colonialism, and racism on Canadian society. It also has principles applicable to other contexts, such as sexism and elitism and homophobia etc.
The concept of “moral authority” is discussed as well, Rolf. The reality is that although we like to believe we hear all voices equally, because of systemic bias, some voices do get to be “louder” than others in our society. We do not get to be the authority on another’s experiences outside our own. We do no get to define another’s narrative. That is what this concept refers to.
Here is a nice quote from anonymous :
“This is the important point: it is only through listening and being willing to engage with and acknowledge our own privilege, and embrace the voice and perspective of others, however challenging and disorienting that this might be, that we can start to engage with and see our own blind spots and ultimately work towards a more equitable society.”
The only thing missing, of course is a clear definition of all those lovely terms. Because, in the end, “privilege” and “blind spots” and “equity” are whatever the nice man (or lady) says they are.
This takes me back to the Maoist Cultural Revolution in China (1966 – 76). The Maoists, here at home (very popular at that time) were big on “self criticism”, of which anonymous has given us a good working definition. Essentially some poor guy would stand up in front of everybody, and share how — try as he might — he still must admit his deep bourgeois prejudices. He would cry. He would plead for help and forgiveness. He would tear out his hair. He would beat his breast. And he would pledge himself to defer to the innate practical wisdom of the peasant and worker. Because, you see, they also had a pecking order of “moral authority”.
Actually, the only difference between Canada and China, in the student activist department of the early seventies, was that over there, they would also roam around the city with torches and sticks, looking for people who needed the cleansing fire of a good “self-criticism” session (assisted with a good beating as well, and a one way ticket to re-education in the rice paddies). But don’t worry though. We are OK. It won’t happen to us. It was only people who read books that had to question their “privilege” in those days. People who wore glasses. People with soft hands.
So yes. I am sympathetic to your subjective experience. But I can’t possibly accept the clingy fingers of a self-referential ideology that wants to plug me into a hierarchical system opposing People to Non-People (of Color).
I just stop at People. Period.
With regards to recommendation number one, how can we use ‘moral authority’ to determine who can and cannot speak? Who is going to determine that? What if people disagree? Everyone should be able to talk and everyone must listen – carefully, with an open mind and (as recommend) with empathy.
About intersectionality, race and gender are only two of the many dimensions in which people can differ. How about socioeconomic background? (see other recent CMAJ blog). What about height? (US presidents are on average quite tall as are CEOs of Fortune 500 companies). Disability? BMI? Beauty? The list is arguably endless. And where does this leave us? It leaves us at the individual. We should focus on that and leave the identity politics behind.
And it is also, by the way, not to those who do not experience this reality to comment on whether this represents “significant” sexism/racism etc.
It impacts my everyday experience as a human being, and serves as a constant, everyday reminder, whether intentional or otherwise, that I do not “belong”; not fully; that I need to constantly prove my right to be here; that I am, simply based on my gender, less worthy, less competent, less fully a physician than I would be if I were male.
And I take this day by day in stride. But do not tell me this is “insignificant”. I deserve the same respect as any male colleague.
I would not normally deign to respond to such ridiculous claims, but just read this article this year if you need a clear, overt example of gender discrimination in medicine:
What I personally find amusing, however, was the shock of the general public when this came out. This was frankly commonplace understanding within the UofT community for years- I had heard countless other residents tell me when I was choosing ER electives not to choose St Joes ER because of the sexism there. Commonplace understanding for years, and no one did anything because this attitude is so common within the medical community it wasn’t worth otherwise noting.
I have seen countless examples of clear discrimination in medicine for both racism and sexism. Anyone who argues otherwise is clueless and happily so. I would not usually be so blunt, but considering the ridiculous claims by some commenters, I have chosen to be.
The reason no one is mentioning medical school admissions (which have only opened up to women in the last century- think about that for a moment; do you really think millennia old discrimination disappears in a century?) is that this is irrelevant to the larger point: implicit sexism and racism is experienced daily by those on the underprivileged side of things, even if overt expressions are being addressed more often.
I have countless experiences I could use to demonstrated this point: being called “sweetie” by a male patient while my male medical student was called “doctor”, although our roles where clearly defined several times; having almost all my orders on one floor at the hospital where I trained being dismissed by the nurses, while 5 minutes later when my male resident colleague asked for the same thing, it was immediately done.
The problem is, that whenever this conversation is introduced, some one will invariably accuse /dismiss/insult those who point it out.
Thank you to all my colleagues who engage in this discussion: white, POC, LGBT, male, female. There are many people advocating for greater equity in this profession, and let us continue to…
First let me express my gratitude towards the ladies (and gentlemen) here, for affording me the opportunity to push back on this most hateful ideology of fake “victims” and fake “moral authority”. We are ALL privileged here. Let us remember that fact.
That said : Nobody has even attempted to dispute my claim that white men are underrepresented in med school at the present time. And the future trajectory is clear. So what ill effects could any person, of any ethnicity or gender, possibly expect to suffer at the hands of the odd white man they might occasionally pass in the corridors somewhere ?
“Moral authority” and Victim/identity, then (at least in the current Canadian context of the liberal professions, including also, law, academia, and the public service), is nothing other than crass triumphalism.
To be clear : There is NO SUCH THING as any significant sexism, or racism, in Canadian medicine.
Please note the use of the word “significant”.
I do indeed know the difference. In fact, I remember a time when the arguments advanced here still seemed rational.
But Canadian society has changed. And it has changed because the people who made up Canadian society (fifty, and a hundred years ago) WANTED it that way.
Now, there is a truly puzzling statement that deserve serious contemplation ! How could that ever have happened ? A fully white and male dominated culture voluntarily, willingly, even eagerly… transforming itself to conform to an ideal of equality, actually INVENTED by white males ? Amazing. What does that mean ?
The physical facts have not changed. Men all around the world from the Taliban in Afghanistan to the Cartel Pimps of Central America are still perfectly capable of laying down the same old violence-based discipline. And obviously white men are biologically the same. So … what makes white men so different ? Why have they, among all others, decided to allow females the status of equality ? (excepting perhaps some rare places with colonial constitutions written under the influence of white men)
Again, these are facts that deserve serious thought… But we have no time to worry about that now.
This is truly an URGENT thing. You (poor down-trodden female, POC, LGBT, and etc. etc.) just don’t have TIME to fool around with imagining you are victims. We need you to step up NOW. All hands on deck ! Rational men and women of all kinds and colors need to be working purposefully, side by side, RIGHT NOW to prevent the whole darn thing from just sliding back into the pre-industrial sludge of our past (where endemic racism and sexism, would be the least of our worries).
Fact : Women are the overwhelming majority of future teachers and professors and doctors and lawyers and public sector management.
Fact : POC (this ridiculous, vindictive, racist moniker which really means “everything other than white”) are the huge majority of the world’s population and soon will be a majority in Canada.
Frankly, what you need to be doing now, is to prepare yourselves for the solemn responsibility of making Canadian institutions work, when you are INEVITABLY saddled with the leadership. Not whining about imaginary “oppression” today !
Wake up ! GROW UP ! You want it ? You got it !
There is nothing to take. nothing to seize. nothing to fight about. It is all falling into your laps, whether you want it or not.
(But, you can’t just grab hold of the fruits of mature western capitalist society, as if it were no more than a strawberry snatched from someone else’s plate ! You also have to take the reins and make the whole thing work. You have to TAKE RESPONSIBILITY.)
(And responsibility is not an easy thing.)
But remember :THIS IS NOT A CHOICE. This is already here. Bets are closed. The wheels are rolling.
Stop whining ! Start working !
(It is only deep affection for my fellow commentators, added to my passion in the outcome, that causes me to adopt a tone more suited to adolescence than age. Please do not waste any energy being offended.)
Thank you for this piece; this is such an important conversation, and at the same time, one that is so difficult to introduce, engage with, and yet is so crucial to actually achieving racial and gender equity in this nation.
That we have come far in the last few decades does not negate the reality that we have still so, so far to go. Every voice pointing this out needs to be recognized and validated. I have certainly witnessed overt gender and racial discrimination in medicine, and Canadian society in general; but even if I have not “seen” it, it does not mean that it does not exist. This is the important point: it is only through listening and being willing to engage with and acknowledge our own privilege, and embrace the voice and perspective of others, however challenging and disorienting that this might be, that we can start to engage with and see our own blind spots and ultimately work towards a more equitable society.
Thank you again for sharing your voice.
Hi Ma La,
“the science shows in fact that the standards are lowered to allow white men access to undeserved positions and grants and that affirmative action is simply extending those standards to everyone”
Framed in that way, this discussion could become extremely complicated, because “the science” shows many things.
However, there is no need, because my claim is much simpler than that :
The favorite metric of injustice today is equality of outcome (as opposed to equality of opportunity).
Roughly seventy percent of the population are white.
Half of those are men.
No where near 35 percent of med-school students are white men.
Ergo, ipso facto, for whatever reason, outcomes are grossly unfair to white men.
But that is not the end of my argument. My actual point, is that victim/identity politics are wrong-headed, severely harming our society, and are, ultimately useless. No one in Canada is interested in “oppressing” anybody anymore. (except perhaps some of the more recently arrived who may not yet have quite succeeded in giving up the traditionally misogynistic and racist values of their erstwhile countries of origin).
Quite simply : As Canada has developed in the last century or two, these diseases are no longer endemic here. And it is a major mistake to deliberately re-introduce them.
Gordon Friesen, Montreal
Gordon Friesen the fact that you think racism does not exist in Canada ‘except those recently arrived with misogynistic and racist values’ shows that you have little understanding of the experiences of people of color. It happens daily in Canada. From people who are not people of color. You may want to ask your colleagues who are POC how and when they experience racism. Consider it a learning opportunity to be open to the truth, rather than downplaying it or presenting it as reverse racism. A traditionally oppressed group’s advocacy for understanding and acknowledgment of their experience isn’t the same as oppressing others. It’s creating awareness to promote better understanding.
Very interesting analysis. Also highly mischievous.
To be clear : in Canada, racial and gender discrimination can not exist openly and structurally in the workplace. Women of all races are now able to qualify and to work in all professions.
Moreover, public opinion (among both men and women) supports the pursuit of opportunity by all motivated individuals, regardless of race or gender.
Even further, most people support the use of artificial methods, in the short term, to improve representative participation, even though that requires artificially disadvantaging specific individuals.
It would be difficult to imagine any greater goodwill or generosity on the part of those presently constituting the Canadian majority.
Therefore, in the current state of Canadian society, the language of “oppression” and “intersectionality’ are, themselves, inherently divisive and counter-productive : the whole point of a just and inclusive society is that ALL members will be offered equal opportunity and respect.
Consider in this light, the quoted principle from the suggested victim/identity play book :
“Consider who has the moral authority to speak and who has the moral obligation to listen.”
Such a principle is simply terrible. Skin crawling terrible. Because EVERYBODY has both the authority to speak AND the obligation to listen. That is the whole point of an egalitarian society.
The current crop of victim justice warriors has espoused this language, for a very simple reason: that in the immediate short-term context, they believe it will advantage them personally (and others who share their superficial identifying characteristics). However, organizing principles of social interaction must be chosen with an eye to their effects in other circumstances also. Without doubt, the unfair conditions of speech suppression which the present authors now wish to impose upon the majority, will eventually rebound upon others also, including themselves.
As a matter of fact, the most obvious under-representation in medicine today, concerns the low number of men ; the more particular disparity in white (majority) men ; and the even greater (arguably sociologically disastrous) disparity involving Canadian-born majority (white) men.
This is a fact. And although we love our immigrant brothers and sisters (not to mention our own wives and daughters), we also have sons. And accordingly, we would wish our sons to be fairly treated, also. But at present. there do appear to be significant structural biases, in the way our public schools and professions are organized, staffed and operated, which positively discriminate against boys (men) generally, and against native born white men in particular.
However, the idea of organizing men (let alone white men) to collectively compete in the victim-identity ideological marketplace would result in absolutely horrible outcomes. (They are. however, rationally inevitable outcomes where real competitive advantage is to be found in such action.
How then, can we avoid these horrible yet inevitable outcomes ?
A much better path, and one which I recommend with the greatest possible warmth, is at once easier and more personally demanding. A risk for each and for all, but a potential benefit of enormous proportions : Trust.
Let us first understand (and admit) that we have all (aside from the most marginal exceptions) come to believe that equality is good. Let us allow people to choose as they wish the paths that they wish. Let us TRUST that people, in real situations, over time will work things out within the non-discriminatory rule of law which we have the unheard-of good fortune to enjoy in our country.
Within a few short generations, we will quite naturally enjoy the shared and equal support and respect that all good decent people (a clear majority) truly desire. In short, we must merely trust ourselves. We will work these things out, because we are free and because as loving brothers and fathers and mothers and sisters, we will support the choices of those we love, in the understanding that they also will support ours.
Such is the true state and promise of Canadian families today : all we need, now, is time and trust.
The suggested alternative, of organizing in ever-more narrow competing collective units, trying for nothing but personal and local advantage, attempting to deny one another “moral authority”, and ignoring the speech of the “other”, is a recipe, not only for disaster, but for long term disaster.
Gordon Friesen, Montreal
The science shows that white men are advantaged. You heard me. The science shows that white men are allowed to fall short of a set standard yet still be passed along as successful candidates. The narrative about affirmative action is always that you have to allow lesser candidates in to improve diversity. But the science shows in fact that the standards are lowered to allow white men access to undeserved positions and grants and that affirmative action is simply extending those standards to everyone. Hard to digest. But science is science. Look it up.
Did you even read the article? You should really look at what was written objectively and consider that you are explaining away something you simply cannot understand as you are not a female and not a person of color. As a non POC who is male, this is one of those times to simply read, consider and try to understand. This is not about YOUR opinion, but about the specific experience of female physicians of color. Your ‘explanation’ comes off as dismissive of their (and my) experience and your opinion on our experience is not desired. Rather, an effort to understand. Your male white privilege screams loud and clear in your post.
There is a difference between intentional, conscious bias and unconscious bias. People don’t need to have bad intentions, or be inherently bad people, to make racist (or sexist) decisions. We are all bathing in a culture of toxic stereotypes, cultural baggage and assumptions regarding race and sex (and other identities) and it’s absurd to think that we can somehow remain unaffected, even with good intentions.
Roodal Ramchandar MD (retired)
Very well constructed and well written essay… thoughtfully written. Thank you, ladies.