What is Happening to My Profession?

Twenty-one years ago, I wrote a book called PC, M.D. How Political Correctness is Corrupting Medicine. One chapter explored “multicultural counseling,” a form of therapy that encouraged white clinicians to ask themselves, “what responsibility do you hold for the racist oppressive and discriminating manner by which you personally and professionally deal with minorities?” Another chapter documented flaws in research studies purportedly showing that physicians, as a matter of routine, were racially biased against their patients. I devoted another chapter to the quest for social justice in the field of public health. In the epilogue, which I called “The Indoctrinologist Isn’t In…Yet,” I cautioned: “those who care about the culture and practice of medicine must be alert to the encroachment of political agendas.”

Today, the Indoctrinologists are officially in. These health professionals argued early in the COVID pandemic that, if hospitals were forced to ration ventilators, they should ration based partly on minority status rather than exclusively by standard criteria, such as clinical need or prognosis. They urged vaccine priority for black Americans to compensate for “historical injustice.” And 1,200 of them cheered, via open letter, the message of an epidemiologist from the Johns Hopkins School of Public Health who told would-be marchers in the wake of George Floyd’s murder that “the public health risks of not protesting to demand an end to systemic racism greatly exceed the harms of the virus.” In each instance, the experts allowed their own moral commitments, not objective metrics of risk, to shape their advice.

The latest manifestation of Indoctrinology is a 54-page document from the American Medical Association called Advancing Health Equity: A Guide to Language, Narrative, and Concepts. The guide condemns several “dominant narratives” in medicine. One is the “narrative of individualism,” and its misbegotten corollary, the notion that health is a personal responsibility. A more “equitable narrative,” the guide instructs, would “expose the political roots underlying apparently ‘natural’ economic arrangements, such as property rights, market conditions, gentrification, oligopolies and low wage rates.” The dominant narratives, says the AMA, “create harm, undermining public health and the advancement of health equity; they must be named, disrupted, and corrected.”

One form of correction that the AMA recommends is “equity explicit” language. Instead of “individuals,” doctors should say “survivors”; instead of “marginalized communities,” they should say, “groups that are struggling against economic marginalization.” We must also be clear that “people are not vulnerable, they are made vulnerable.” Accordingly, we should replace the statement, “Low-income people have the highest level of coronary artery disease,” with “People underpaid and forced into poverty as a result of banking policies, real estate developers gentrifying neighborhoods, and corporations weakening the power of labor movements, among others, have the highest level of coronary artery disease.”

Although the guide contains page after page of “medical newspeak,” as linguist and New York Times commentator John McWhorter called it, a solid kernel of truth lies buried within it. The guide rightly calls attention to the “social determinants of health”—the psychological, social, and cultural contexts that contribute to disease and shape people’s choices regarding their health. The increased awareness of these contexts over the last 20 or so years has been a major advance in medical training. It is indeed important for doctors to realize that even their most motivated patients may not be able to afford a medication, take time from work to keep an appointment, or understand a complex medical regimen. We must be prepared to enlist social workers and case managers to help.

However, the guide recklessly stretches context beyond the realm of clinical outreach. It rebuffs “programmatic fixes,” such as the case manager who arranges for a patient’s transportation, because such fixes “ignore the social responsibility of corporations and government agencies.” With its emphasis on “power relations” and its push to “redistribute power and resources,” the guide reads more like a postmodern manifesto than an actionable blueprint for physicians.

In important ways, I hardly recognize my profession. After the death of George Floyd, however, the radical justice project caught fire. Last year, the Association of American Medical Colleges, a major accrediting body, informed medical schools that they “must employ anti-racist and unconscious bias training and engage in interracial dialogues.” One of my colleagues told me that her school jettisoned lectures in bioethics to make room for the anti-racist curriculum. “Which is ironic,” she said, “because that was where students were taught about subjects like the Tuskegee syphilis experiment.” What other essential subjects will anti-racism training displace?

The implementation of the social justice agenda has constrained collegial discourse, challenged the maintenance of standards, and suppressed honest analysis of certain problems. In her article called “What Happens When Doctors Can’t Tell the Truth?,” Katie Herzog wrote of “doctors who’ve been reported to their departments for criticizing residents for being late. (It was seen by their trainees as an act of racism) … I’ve heard from doctors who’ve stopped giving trainees honest feedback for fear of retaliation. I’ve spoken to those who have seen clinicians and residents refuse to treat patients based on their race or their perceived conservative politics.”

Two cancellations have attracted notice. Last year, Norman Wang, a cardiologist at the University of Pittsburgh School of Medicine who expressed skepticism about mandatory affirmative action after conducting a careful review of the data was stripped by his department of his directorship of the electrophysiology fellowship and barred from having contact with medical students, residents, or fellows because his views were “inherently unsafe.” His peer-reviewed paper, ‘Diversity, Inclusion, and Equity: Evolution of Race and Ethnicity Considerations for the Cardiology Workforce in the United States of America from 1969 to 2019,’ which appeared in March 2020 in the Journal of the American Heart Association (JAHA) was retracted by the journal without Wang’s consent. The American Heart Association, which publishes JAHA, tweeted that his article “does NOT represent AHA values.” The cardiologist has sued both the university and the American Health Association.

In another case, the editor-in-chief of the Journal of the American Medical Association was effectively forced to resign last June for a somewhat tone deaf, but otherwise unremarkable, 15-minute podcast on racism in medicine and because of a tweet advertising it. “Although I did not write or even see the tweet, or create the podcast, as editor-in-chief, I am ultimately responsible for them,” he said in a statement. What other examples have escaped attention? “Most who are troubled by this are keeping their heads down and keeping their mouths shut,” said my colleague Thomas Huddle, an internist and professor who retired this year from the medical school at the University of Alabama at Birmingham, one of the few physicians willing to go on the record. “They’re deeply afraid of social media mobs and of academic administrative superiors who’ve taken this stuff on,” he said of his colleagues to Real Clear Investigations.

Especially vexing, as Huddle and I have commiserated, is the reflexive attribution of group differences to systemic racism. “It’s axiomatic at this point,” said a colleague who had participated in a group discussion of stress and rising suicide in black youth. The tacit rule was that only fear of police aggression and subjection to racial discrimination were allowable explanations, not the psychological torture of bullying by classmates or the quotidian terror of neighborhood gun violence.

I strongly agree that much of black Americans’ disadvantage in health and access to care is the cumulative product of legal, political, and social institutions that have historically discriminated, and sometimes continue to discriminate, against them. Systemic racism may indeed have broad explanatory value regarding health disparities, but, as an analytic framework, it doesn’t yield realistic prescriptions. Just what are physicians supposed to do? Become activists? The AMA’s answer is yes. In a strategic plan it released last spring, the organization urged doctors to “push upstream to address all determinants of health and the root causes of inequities, dismantle structural racism and intersecting systems of oppression.”

This is no solution. Physicians cannot—and should not—“dismantle racism and intersecting systems of oppression” as part of their clinical mission. To imply that such activity falls within our scope of expertise is to abuse our authority. Doctors can reasonably lobby for policies directly promoting health, such as better coverage for patient care or more services, but we will lose our focus and dilute our efforts to care for patients if we seek to address the perceived root causes of health disparities.

After all, even seasoned policy analysts can’t readily tease out strong causal links between health and sprawling upstream economic and social factors. With so many intervening variables at play, reforms in the service of health may well create unwanted repercussions elsewhere in the system. Any physician is free, of course, to pursue progressive reform as a private citizen but, as doctors, we already have a job: to diagnose and treat.

Still, much can be done to expand immediate access to treatment for underserved minority populations. In California, for example, when patients with colon cancer were treated at an integrated health care system—a point of entry where all aspects of care were delivered under one roof—black patients fared much better than black patients treated in usual settings. As a result, survival rates were the same for blacks and whites. The Metropolitan Chicago Breast Cancer Task Force reduced mortality by helping women, mainly black women, navigate the health care system. The Comer Children's Pediatric Mobile Medical Unit brings service to Chicago's South Side, including immunizations, physicals for school, and screenings for vision, hearing, lead poisoning, and anemia. Medical centers partner with inner-city barbershops to help black patrons control diabetes and high blood pressure and to prevent heart attack and stroke. These community-based projects may not be the seeds of revolution, but they can improve and save lives.

On January 8th, 2021, I had my own encounter with intolerance in academic medicine. Via Zoom, I gave a Grand Rounds lecture to the Yale Department of Psychiatry, where I had been a resident for four years and an assistant professor for five. I left New Haven in 1993 to pursue a health policy fellowship in Washington, DC and eventually joined a think tank there, but remained a lecturer in the department. My talk was about the year I spent assisting with treatment efforts in Ironton, a small, embattled town in south-eastern Ohio that was reeling from the opioid crisis.

I discussed the “deaths of despair” phenomenon and showed photos of haunted industrial landscapes and the lonely downtown area. I presented national data on the characteristics of individuals who abused prescription pills and on the frequency with which addiction develops. I talked about the culture of prescribing in rural mining towns and the myriad factors that caused the crisis. I closed by highlighting the heroic efforts of Irontonians to boost the economy and the morale of their beloved town.

One month later, I received an e-mail from the chairman of the department, a fine man and brilliant researcher whom I have known since we were interns together in the 1980s. He admitted that he had not anticipated “the extent of the hurt and offense that folks would take” to my presence. He appended an anonymous complaint that he had received from an unspecified number of “Concerned Yale Psychiatry Residents.”

The residents told the chairman that my talk, coming only two days after the January 6th attack on the Capitol, “was further traumatizing to us.” They wrote that, “the language Dr. Satel used in her presentation was dehumanizing, demeaning, and classist toward individuals living in rural Ohio and for rural populations in general … We find her canon to be beyond a ‘difference of opinion’ worth debate.”  My earlier writing on health disparities was deemed a “racist canon.” They expressed “shock and disappointment” at the chairman’s failure to “take a public stand against” me and questioned his commitment to the department’s anti-racist agenda. “Will you continue to invite Grand Rounds Speakers with racist and classist mindsets, like Dr. Satel?” the residents asked.  Although they requested that the chairman “revoke” my lectureship at Yale, he did not do so.

Academic medicine is in the midst of a risky institutional experiment. How will the AMA’s new call to “focus attention on inequitable systems, hierarchies, social structure, power relations, and institutional practices” affect the formation of trainees’ professional identities? Are we truly to believe that health is so thoroughly contingent on malign forces that doctors shouldn’t bother educating patients about how they can take responsibility for their wellbeing? And how will the adoption of a zealous social justice agenda affect public trust?

Some of the people who are refusing the life-saving COVID vaccine are alienated from mainstream institutions, which they view as house organs of the political Left rather than trustworthy arbiters of truth. They may see the AMA’s prescription as further confirmation of their suspicions.

Most important, will patients benefit when the AMA and other leaders position medicine as a vehicle for activism? We must remember that “Do no harm” is a covenant that doctors make with their patients, not with political systems and hierarchies.


This is a companion discussion topic for the original entry at https://quillette.com/2021/11/30/what-is-happening-to-my-profession/
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What’s the NNTV?

I’ll be honest I’m one of these “refusers” who is alienated from the mainstream institutions and I wasn’t aware of any of this particular wokespeak permeating the medical profession. It’s going to take a lot more than ridding the medical world of wokeness to win back the alienated people like myself. The entire COVID-19 narrative is a farce, based on heavily skewed numbers that can’t be trusted. I can roll my eyes and dismiss progressive BS but I can’t so easily dismiss the push to panic and frighten millions of people like Chicken Little when it comes to matters of public health and safety.

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The author complains about wokeness, then in a flourish, refers to “Some of the people who are refusing the life-saving COVID vaccine . . . .”

Seems like a gratuitous bit of virtue signaling to me, especially in light of all we now know about the “vaxx.”

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Alert! Alarm bells going off, lights flashing, buzzers buzzing. The speaker/writer is ranting - take whatever’s being said, with a gain of salt.

What does it mean that “the entire narrative is a farce?” As I read it: in the body of work being referred to (“the entire narrative”), there’s not one true thing. But it is hard for me to think of “narratives” that are 100% false. Even opinions, analyses, statements, points of view that I despise and/or strongly disagree with, typically have some truth to them. Just mixed in with lots of other stuff.

Then, about “heavily skewed numbers that can’t be trusted.” Numbers certainly can be skewed, and this can sometimes be done deliberately. So, whether a particular set of numbers can or cannot be trusted, is a decision for each individual to make. To say that one set of numbers can’t be trusted implies that no (sane, rational, competent) individual could reasonably trust them. Typically this kind of statement is based on ad hominum (or perhaps in this case, ad institutionem) attacks. Someone or some organization/institution is painted as so diabolical, motivated, evil, untrustworthy, that “you can’t believe a word they say.”

I actually agree that that can be a correct attitude to take in some cases - this is an old rule: “consider the source”.

But if we don’t have the time, resources, or inclination to do that, a common strategy in deciding whether to trust some set of numbers (or statistics) is, to compare what the statistics say, with our own personal experience.

This is easy to do with COVID. My sister-in-law is working long days as a respiratory therapist in a trauma center. Probably you know some health care worker - or at least you know someone who knows one. The stats say that about 90% of COVID deaths and hospitalizations are of unvaccinated people. Just ask the front-liners if this is true and they will tell you, yes, it is.

The stats also say that COVID cases are overwhelming our hospitals. Just one personal attestation I just heard (unsolicited) yesterday: “In my entire hospital, only one patient is not COVID.” This from a small local hospital with 25 beds.

We’re thinning the herd here, sorry to say. I don’t believe in the death penalty for ignorant behavior, I really don’t. But the real world doesn’t care if I think something is fair or not. Do unhealthy things and you will generally pay the price. In times of heightened threat, that price may be, your life. Or the life of a loved one. Or, sadly, some stranger whom you infected…

This is not the first time I’ve witnessed this sort of thing going on. I knew people who died from AIDS, and family members of same, back before there were treatments. They were a sad mix of folks who did unhealthy things, when they should have known better; and others who were just unlucky.

At some point I need to stop lamenting ignorance because there’s just too much of it out there. Time for me to go measure my shed and put some doors on it.

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From such behavior at the Yale Law School, I guess I’m not surprised that the woke cancer has reached the medical school as well. If I needed psychiatric care (debatable according to my wife), I’d not entrust it to one of those sensitive residents Satel describes.

If a white patient refused service by a black doctor, imagine the uproar.

Given that the think tank Satel is a member of but doesn’t name is the American Enterprise Institute, a conservative one. I’d place a bet that the angst over her talk was generated when that fact came to light.

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AEI is rather more a neo-conservative, laissez-faire capitalist, open borders and globalist institution than simply a conservative institution. All of the Bushies in 2002 had connections to AEI.

I thought the article was right-on.

(FWIW - it’s OK for conservatives to think the vaccines are great. I’m a clinician and a conservative. At my facility I see huge differences in every measure of COVID severity - hospitalization, critical care, death - between the vaxed and un-vaxed. I recommend vaccines to lots of folks. Just sayin’. Bad-mouth me all you want, I don’t care.)

I’m hearing a lot about this wave of woke bullshit among new docs from older physicians. In many cases I’m hearing it from docs who are pushing retirement age, and, as far as they’re concerned, none too soon. They will be replaced, more and more, by woke nimrods. The Marxist’s long march thru the institutions has been wildly successful.

The problem I do have with articles like this is what’s being left unsaid - what’s the solution? What countermeasures can people take? I have my thoughts, but what are theirs?

I’d ask Quillette to ask it’s contributors to try to address this question in these kinds of articles.

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I completely agree. The same is true of education. What does it mean to say that schools, colleges and universities are “systemically racist”? Almost nothing, as far as I can tell. This kind of self-flagellating virtue signaling leads administrators to propose pseudo-solutions to a pseudo-problem – by employing overpaid consultants, hiring more DEI bureaucrats, requiring anti-racist training, etc. – instead of focusing on pragmatic, evidence-based approaches that can help students succeed. Are non-white college students really dropping out of school without earning a degree because of micro-aggressions on the part of faculty? I sincerely doubt it. They face the same obstacles as their white counterparts: insufficient academic preparation, concern about accruing excessive debt, family obligations, the need to work a full-time job in addition to being a full-time student, etc. If we want to increase retention and completion rates for first-generation college and otherwise disadvantaged college students of all colors let’s address those problems instead of fixating on race.

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Farce doesn’t have to do with what’s true. I use it to mean a grotesque joke. I could have just as easily said disgrace. I do believe the level of truth within the narrative to be some nonzero portion of it, we can agree on that. There is truth to many a joke.

Agreed.

Agreed again! 3 for 3, Stan! I contend that no rational person could reasonably trust the case numbers (knowing what we do about the accuracy of PCR testing) or the “covid death” numbers (knowing what we do about people dying of cancer or in auto accidents whose deaths are officially attributed to COVID-19).

Here’s where we start to disagree. Whether I’m doing this in thread myself, I highly doubt it is typical for someone to be committing ad hominem if they say a set of numbers can’t be trusted. Esp if they have given valid reason for those numbers being untrustworthy.

I dont see why front-liners like essential liquor store and cannabis store workers would know anything more than your average non-essential worker like a restaurant owner, but I know by front-liners you meant the healthcare workers only, and I know that by the healthcare workers you mean only those ones who may speak their views freely without fear of reprisal and not the ones who have lost their jobs for saying things contrary to what you say they’ll tell me.

But of course those ex-healthcare workers aren’t front-liners anymore, are they? Touche.

Of the remaining front-liners available for me to ask, how many will be protecting their livelihoods when they answer just how you predict they will?

This is nothing new. It’s always something.

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How many of those contracted COVID within that small hospital’s walls after being sent there for unrelated reasons, like my friends father who contracted COVID in the hospital after being admitted for a severe downturn of an existing condition for which he was likely to die with or without COVID. People like him all over the world contribute to the narrative’s big scary numbers.

It comes as absolutely no surprise to me that COVID spreads like wildfire in a hospital setting, and it comes as no surprise that those who work within that setting (esp after culling the ones who refuse to kneel) would be the most likely to blow this out of proportion.

Are we?

It seems to me if we wanted to thin the herd then we should target those not already on deaths door. If we wanted to thin the herd, then what we should do is target children before they come of reproductive age.

See this is what I’m talking about when I say farce. Comparing doing unhealthy things like promiscuous unprotected sex to unhealthy things like gathering with friends and family to throw a child a birthday party. I find it to be a sick joke.

If you’re accusing me of being ignorant then I must ask, of what?

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But they experience higher rates of non retention & completion than whites from a of higher level of multiple disadvantages than them. Generational poor role modelling, crime ridden poor neighbourhoods, gang culture, fatherlessness, addiction, health problems, higher rates of incarceration etc in a cumulative pattern results in an increased level of racial barriers.
I agree similar solutions are required but there are minority communities that may need a more intense focus.

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That’s it @Ella-B - the uncomfortable questions……you’ve mentioned some of them. Is American society able to broach these issues without it devolving into a morass of side-picking and diversion?

I see the pandemic as an amazing opportunity for self-reflection, both individually and societally. Whether we take pause and give air to the festering sores just below the surface of society, or put more Band-Aids over the wound without treating the infection will be interesting to watch.

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This is the worst you have to fear on this front, isn’t it? Some jokes. Some “when people choose blood clotting over cold symptoms” memes.

Both sides get memed, maybe not in equal quality but that’s more than balanced out by your not having to worry about people coming for your job or your freedom of movement. So it’s quite easy for you to stand up and be brave in the face of some badmouthing.

Will your ideas about how to deal with woke Marxists virtue signaling in medicine be effective against this techno-totalitarian creep as well? Because I think the latter is the more serious issue.

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Welcome to activism mate. It’s time to get your Greta on…
I would also add other than activism supporting a bigger effort to address serious racial disadvantages because not doing so creates fertile ground to justify the micro aggression barbarians to storm the gates.

Do we really need to turn this thread into yet another vax vs. anti-vax debate? I doubt anyone has anything new to say.

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I don’t see how factoring race into the equation helps in any way. In my view, programs designed specifically for POC are divisive and patronizing. It may be true that poor blacks face more obstacles (on average) than poor whites, but race-neutral policies enjoy far broader support and are more likely to be implemented.

I feel the same way about BLM. Activists could have built a broad-based coalition to reform policing if they had identified problems with policy brutality and advocated for pragmatic solutions. Instead, the issue was racialized (more often than not, on the basis of false narratives and misleading data) and became a flashpoint in the partisan culture wars.

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We don’t need to do anything. You replied to a post in which I said nothing about the merits of the vaccine either way. Is “anti-vax” just some kind of catch-all for heretic?

What a silly thing to say. New information is constantly coming out because there is so much that was unknown when the rollout began. For instance did you know that British Health Secretary Sajid Javid recommended the minimum time between boosters to be halved from 6 months to 3?

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In the workplace, all white people should resign their positions, with the caveat that only black people can fulfill the role! Any severance they might receive should be added to the paychecks of the new hires, as reparations!

Due to issues of cultural appropriation, white people should stop eating at restaurants that serve authentic Indigenous or native food! White people may benefit from learning new cooking techniques, which can then be used against such populations when they cook at home, for example, or start their own restaurants!

Retail establishments should offer Sidewalk Days where they put their merchandise out for others to take as they need. This would reduce the trauma associated with having to build back better crews who may otherwise need vehicles to crash through store fronts in order to access the goods they need to resell later to buy diapers and formula!

These acts and others like them will keep the micro aggression barbarians away! A little proactive wealth distribution will soften those barbarians into fuzzy little puppies!

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Wow! Thanks for the oh-so-important update! This. changes. everything.

You should definitely start a new thread based on that bombshell development!

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But they won’t work for those with severely entrenched problems without targeted community assistance or investment inviting the same old systemic racism claims again.

I don’t see there’s a choice here. And in any case the unpopularity isn’t because people prefer race neutral policies rather they believe there’s already a perfectly good one called the bootstrap policy…