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I’m Done Wearing a Mask: Part 2 | Renee Cowan, MD, MPH

DiversityInclusion & Health Equity
Oct 22, 2020

Renee Cowan, MD, MPH

Last month SGO Issues published Part 1 of an essay written by a Black fourth-year gynecologic oncology fellow. This month we continue with Part 2, detailing three steps for how we can all move forward in eliminating healthcare disparities for women with gynecologic cancers.

From last month: Addressing healthcare disparities is an actual work with a real process. If you’re asking yourself, “What can I do?” keep reading.

Re-examine how you treat your patients

Being Black is more than a race, it’s a culture and heritage. I have no doubt that you are a good physician. We may debate the risks and benefits of minimally invasive radical hysterectomies and bowel preps, but at the end of the day we all want to do right by our patients. We joined this field to do good, to help, to serve, to heal. We also come with our own subconscious biases and preconceived notions. Often, we may not be aware of how our actions or words can affect the women who we have taken an oath to care for. I want you to think twice before labelling a Black woman as angry, crazy, difficult, dramatic, noncompliant, or even feisty, sassy, or funny. As with any culture, there are certain nuances that others not from that culture may not understand. Kissed teeth or pursed lips do not always denote a bad attitude or even dismay. Refusal to participate or accept certain aspects of your care can be noncompliance, but more often it’s a sign of fear, mistrust or misunderstanding.

Just this year I got an email to consult on a Black patient who was refusing chemotherapy. Her medical oncologist, who was not from an under-represented minority group, felt unable to get through to her, and instead requested that the surgical team talk to her and tell her to explain that there were no more surgical options, with the goal to place her on hospice. Another non-URM provider from my team went to see her and concluded that the woman was “crazy” and perseverating about immunotherapy- induced GI dysfunction. I sighed and agreed to see her in the morning. The next morning, I spent some time talking with the patient to listen to and explore her concerns, only to find out that she was scared of systemic therapy due to a previous negative experience she had with immunotherapy. She was sure she was dying and that there was nothing that could be done for her. By the end of the conversation we had her on the schedule for carboplatin on the following Wednesday.

Is this a testament to me being an amazing doctor? No…it’s a story about how taking a moment to understand your patient’s perspectives and background can be the best treatment. She didn’t need a surgeon, she needed someone to meet her where she was, see through her tough exterior and get to the core of the matter. Keep this in mind when you’re dealing with a seemingly “difficult” Black (or otherwise) patient. Can some patients of all race/ethnicity or backgrounds be difficult and draining ? Of course! However, take a second and make sure that you’ve made it clear that you are a safe space for your minority patients. Make sure they know that it is your goal to provide them with the best possible care. This isn’t Tuskegee all over again. You don’t just want to experiment on them. You want to serve them. Once you’ve taken the time to truly establish rapport with your personal group of Black patients, you can start thinking about access to care, survival differences, and the like.

Re-examine your relationship with your Black trainees

A vital intervention to narrowing the treatment gap for Black women with gynecologic cancer is to increase the number of Black gynecologic oncologists. We have all had patients that we’ve connected with on a deeper level because they reminded us of our mother, grandmother, daughter, niece, aunt. It’s nice. Could you imagine if during the course of your healthcare journey you never came across with anyone that you connected with, no one that looked like you, or understood your cultural background? Representation matters and is invaluable . In the same way that my Russian speaking co-fellow has a special bond with her Russian patients, or my Jewish colleagues can share a Sabbath blessing with our Jewish patients; there is a way that I can interact with my Black office staff, nurses, colleagues, and patients that my White colleagues cannot and THAT IS OKAY. It’s a cultural thing, not a prejudice thing, not a reverse racism thing. There’s no need to be color blind or culture blind. We can do better by our patients by increasing diversity and representation amongst ourselves as gynecologic oncology providers. Do you have any idea how many times a Black woman has called me back to her room just to tell me how happy she is that I am here?

If you have decided that you want to be on the right side of history and fight disparities, then don’t be afraid to cause a little “good trouble.” Speak out. Think about your own journey. How did you decide on gynecologic oncology? How were you supported? Who were your mentors and your sponsors? They aren’t always people who looked like you or were from where you were from. Have you come across a Black medical student or resident who might have had “good hands” or a special compassionate approach with your patients? Tell him or her! Let them know that you think they could do what you do. You don’t know who has been secretly watching or admiring you thinking that they could never do what you do. Find someone who is interested? Go one step further and mentor them or sponsor them. Introduce them to your colleagues, the movers and shakers in the field. Make a call for them. Help them navigate the nuances of academic medicine. Vouch for their clinical skills even if their Step or CREOG scores aren’t as high as some of their classmates.

Don’t be afraid to grant your Black applicants the same graces that you grant to the applicants who have had one of your trusted colleagues call on their behalf. Don’t be afraid to speak up and say, “Hey, maybe we should take a second look at this Black applicant again.” I don’t think my mentors and sponsors spoke up for me because I was Black specifically, but I know for sure that I could not have made it here without them. I recognize that ALL trainees matter and need support, but your Black trainees are going to require intentional support to help them achieve amidst the obstacles they will face in and out of the hospital.

Re-examine your mindset

While we are on the road to justice (removing the systemic barriers that lead to disparities) we have to decide whether we are fighting for equality or equity. Equality means that everyone gets treated the same. It sounds simple enough and like something we should all get behind, but let me ask you this: if we’re going apple picking and give the short person and the tall person the same 1-foot ladder to reach the fruit, who can actually reach the fruit? Compare that to equity, where you give each person the tools they need to accomplish the goal. This means you give the shorter person a taller ladder so he or she can reach the apples. How does that sit with you? How do you feel about giving someone who has historically had less advantages more help or more resources so that they can achieve the same goals as the people who have historically had more resources? Let’s put this a different way, how do you feel about special grants for Black researchers? How do you feel about accepting Black fellowship candidates who have less publications, don’t seem as polished, or come from community programs? Take a moment and let that sit in your soul before you decide you want to be an “ally,” an “anti-racist,” or do “disparities work.”

To conclude, a note to my Black trainees considering gynecologic oncology—You deserve to be here. You will be different. You will feel alone sometimes. But trust me when I say this, your presence is needed. Don’t be afraid to reach out and find the support you need to make it down this arduous path. The road is long and narrow, the journey trying and difficult, but once you reach the end it will be worth it not only for you, but for your family, your patients, and the people who have tread this road before you. So act justly, show mercy, and walk it humbly, but with your head unbowed.

Renee Cowan, MD, MPH, is a fourth-year gynecologic oncology fellow at Memorial Sloan Kettering Cancer Center in New York City. Prior to fellowship she completed residency in Washington DC at MedStar Washington Hospital Center and medical school at Temple University in Philadelphia, PA.