The current COVID-19 public health crisis is affecting everyone, but is acutely impacting those working in the health care field. A Morning Consult survey polling 1,000 healthcare workers across the U.S. in January 2021 found that almost one in two workers reported that their mental health and daily life had worsened during the pandemic, close to one-third reported worsened physical health, and over one-third reported that their career, work life and financial situation had gotten worse.
There is also the trauma of working on the frontlines during a pandemic with strained resources. Workers have had to care for patients recovering from COVID-19 while fearing for their own health and, at times, having to witness it take the lives of those they cared for. This inability to provide patients with quality health care can lead to a psychological guilt referred to as moral injury. Individuals in the health care field may often experience other serious mental health issues such as post-traumatic stress disorder, depression, anxiety, or suicidal ideation.[2] The various demands that health care workers have to meet can also exacerbate this psychological weight. These can include having to consider the financial needs of patients, hospitals, and insurers; ensuring accurate documentation in electronic health records; and meeting metrics to ensure funding, while also balancing patient satisfaction, which can greatly affect those metrics. [3]
This inability to provide patients with quality health care can lead to a psychological guilt referred to as moral injury.
For non-white health care workers, particularly those in the Black diaspora, effects like these are compounded by the negative impacts of another more devastating public health crisis: racism. Systemic racism is at the root of creating and perpetuating inequities in all systems as current policies and practices continue to be upheld, including in the health care sector. First, the field of medicine is one that is dominated by white males. According to a 2019 “Diversity in Medicine” report by the Association of American Medical College (AAMC), 56 percent of physicians identified as white, 17 percent as Asian, 6 percent as Hispanic, 5 percent as Black or African American, and less than 1 percent as either American Indian or Alaska Native or Native Hawaiian or Other Pacific Islander.[4] There is also segregation along racial and gender lines in the workforce. Black and Brown people are often “concentrated in female-dominated direct care and reproductive occupations, occupations that reflects our historic dependence on women of color—and especially Black women—to perform the “dirty work” in domestic spaces as slaves, servants, and low-wage workers.”[5]
Racism also manifests in the discrimination and microaggressions Black and Brown health care workers experience when interacting with patients and colleagues. Personally, I have also worked in health care and can remember the uncomfortable culture that is often pervasive in hospital systems. Once, a nurse manager commented that they thought that my braided updo was a hat in a previous position as a hospital unit secretary. A review of nineteen studies reporting on discrimination experienced by physicians of color confirmed a high prevalence of occurrences like this, and that Black physicians experienced it at higher rates than any other non-white group.[6] Anecdotes described feelings of isolation, and examples of discrimination included overt comments or acts. However, the most prevalent forms of discrimination were those that were more subtle, such as, “inadequate institutional support, exclusion from social networks, devaluation of research on minority health or health disparities, and a lack of institutional commitment to advancing diversity.”[7] Black and Brown physicians’ credentials are often questioned by colleagues and patients alike, a trend that is particularly true for Black female doctors.[8] Some common occurrences can include patients (and even colleagues) assuming Black physicians are janitors, food servers, or technicians, even when wearing the distinctive white coat. Patients may also refuse care or use derogatory terms when referring to Black employees. They can often be more likely to rate them lower in patient satisfaction surveys than their white counterparts for issues that do not relate to care or a physician’s duties, such as “cleanliness of the clinic."[9]
Black and Brown physicians’ credentials are often questioned by colleagues and patients alike, a trend that is particularly true for Black female doctors.
These individuals daily carry a double burden of advocating for Black and Brown patients, while working to prove themselves to patients and colleagues and simultaneously facing the injustices of racism themselves every day. While some show great courage in advocating for themselves and patients like them, there is a cost that comes with doing so. Others may suffer in silence, only adding to their moral injury, as they choose self-preservation out of fear or lack of organizational support. With no protections in place for employees against patient discrimination, Black and Brown health care staff may often tolerate microaggressions due to the pressure of needing to acquire high patient satisfaction scores to help secure public investment in the hospital systems they are a part of.[10] Many may grapple with having to balance protecting one’s sense of self and mental health while providing quality care to patients who (consciously or subconsciously) devalue their abilities and identity. This balancing act creates tension between patients and staff that can hinder the quality care of patients, as well as the mental and emotional safety of the Black and Brown health care workforce. Collaboration can also be hampered as individuals may feel isolated at work when their peers do not support them when witnessing discrimination from patients, or hearing microaggressions coming from other colleagues.
AAMC projected that there would be a shortage of 54,100 to 139,000 physicians by the year 2033 in a new study.
AAMC projected that there would be a shortage of 54,100 to 139,000 physicians by the year 2033 in a new study.[11] This projection was completed before the start of the COVID-19 pandemic. With the compounding stressors from the demands of the profession, systemic and individual racism, and a pandemic, underrepresentation of Black and Brown physicians, nurses, and other health care workers may only increase. Many often consider leaving institutions or have quit jobs due to dissatisfaction and a lack of support in issues related to racial equity. It has already been proven that representation can have positive effects on patient health. If organizations do not take steps to protect employees and offer additional resources to support them, communities and the field of medicine alike will suffer from a deepening lack of diversity as whole groups of people are already and will continue to be underrepresented.
[1] Galvin, G. (2021). ‘We Are Burned Out:’ Nearly 1 in 2 Health Care Workers Say COVID-19 Has Harmed Their Mental Health. https://morningconsult.com/2021/01/25/we-are-burned-out-nearly-1-in-2-health-care-workers-say-covid-19-has-harmed-their-mental-health/
[2] Hendrickson et al. (2021). Health care workers’ suffering goes far beyond burnout. Self-care isn’t the cure. https://www.statnews.com/2021/12/16/health-care-workers-suffering-goes-far-beyond-burnout-self-care-isnt-the-cure/#:~:text=The%20survey%20suggests%20certain%20experiences,patients%20dying%20from%20Covid-19.
[3] Talbot, S. & Dean, W. (2018). Physicians aren’t ‘burning out.’ They’re suffering from moral injury. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/
[4] Association of American Medical College (AAMC). (2019). Diversity in Medicine: Facts and Figures 2019. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018#:~:text=Diversity%20in%20Medicine%3A%20Facts%20and%20Figures%202019,-New%20section&text=Among%20active%20physicians%2C%2056.2%25%20identified,as%20Black%20or%20African%20American.
[5]Dill et al. (2020). Addressing Systemic Racial Inequity In The Health Care Workforce. https://www.healthaffairs.org/do/10.1377/forefront.20200908.133196/full/
[6]Filut, A., Alvarez, M., Carnes, M. (2020). Discrimination Toward Physicians of Color: A Systematic Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253328/
[7] Id.
[8] Molina et al. (2020). Addressing the Elephant in the Room: Microaggressions in Medicine. https://www.fammed.wisc.edu/files/webfm-uploads/documents/diversity/microaggressions-everyday-life.pdf
[9] Williams, J. (2021). The ‘Black Tax’ and COVID-19: Amid Pandemic, Black Doctors Carry Double Load. https://www.usnews.com/news/health-news/articles/2021-02-01/black-doctors-covid-burden-patients-social-ills-and-workplace-bigotry
[10] Filut, A., Alvarez, M., & Carnes, M. (2020). Discrimination Toward Physicians of Color: A Systematic Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253328/
[11] Boyle, P. (2020). U.S. physician shortage growing. https://www.aamc.org/news-insights/us-physician-shortage-growing
