“Well, if I go home and have another mental breakdown are they gonna shoot me too?”
This is what my 14-year-old Black female patient, hospitalized with suicidal ideation, said to me. She had found herself at the intersection of twin epidemics of gun violence and mental health crisis, too often experienced in tandem by patients in the community I serve. As her words reverberated in my head, all of my usual communication tools evaporated. I could not in good faith tell her that there was a zero percent chance of this happening. I could not tell her “things will be okay.” I could not tell her that the problems she faces are surmountable. Because sometimes I don't know if they are.
As pediatricians, we train for years to become not just astute clinicians, versed in the science of pathophysiology and pharmacology, but also capable communicators. We learn how to present on rounds among both medical teams and families; how to manage challenging interactions with patients, peers, and superiors; and how to deliver serious news. While only a select group may consider themselves experts in navigating these scenarios, we all have at least some experience and training in communication best practices. During my past year as a Chief Resident and General Pediatrics hospitalist, I tried to support residents and medical students in developing their communication practices, while simultaneously working to refine my own.
Despite this, there have been several times when I have found myself in conversations with patients and families where I simply do not know what to say, or how to say it. I remember caring for a hospitalized Black 2-year-old with cellulitis in the midst of protests about Walter Wallace Jr.’s murder in Philadelphia. The patient's father and I spent nearly an hour discussing how to optimize their discharge timing so that they could safely get home. The streets in his neighborhood were closed off, the grocery store had been shuttered with thick wood boards covering the windows and doors, and the only nearby pharmacy had been ransacked. He wasn't sure how he would secure transportation home, much less how he would get milk, diapers, and medications for his son. The entire conversation embodied the concept of the elephant in the room. How could I have said, “I'm so sorry that we have to plan your hospital discharge to ensure that you stay safe in the setting of the unrest in our city due to the murder of (yet another) a Black man?”
How do we broach the topics of politics, racism, and structural inequity with patients and families? Something so pervasive still feels so hard to address, perhaps because of its very ubiquity. Though I continue to educate myself on the history and current state of racism, have taken steps to become an active antiracist, and have experienced discrimination myself as a Latina woman, I still often find myself grasping for the right thing to say. I mention this not to tout my personal experience, but to highlight that these conversations can be hard for even the most well-intentioned clinicians, who each meet patients with their own unique education, beliefs, and background.
I'm not sure what the ideal conversation is to have about race at the bedside, but throughout this past year, I have become more and more certain that some conversation needs to happen. I have been struck by how freely and frequently we talk about other aspects of our society, like the ongoing COVID-19 pandemic, with our patients. Is racism not an equally pervasive and deadly foe? Is it not a scourge that constitutes its own pandemic, hundreds of years long, with millions of victims and an ever-growing daily death toll? The centuries of institutional oppression follow us into the hospital room, like a weighty wight on the shoulder of our white coats, making us feel it must be addressed while simultaneously also making us feel so small beneath the heft of historical hatred, discrimination, and devaluing of human lives. We owe it to our Black families to ensure they know we stand alongside them in this battle.
I often find myself torn between wanting to offer support and solidarity, and not wanting to initiate a conversation that a family would prefer not to have. As a bridge, I wear a Black Lives Matter pin—a means of signaling my allyship. I hope this serves a way of saying “I see you” without saying it. When families do open the conversation around race, I engage, even if I worry that I don't have the right words. And when CNN is blaring in the background declaring that Derek Chauvin has been found guilty for the murder of George Floyd, I ask my patient and mother how they are doing. I save the platitudes and comments that I might say to make myself feel better. Instead, I sit and really listen to what they say.
I know that everything I said to my teenage patient that morning in response to her tragically honest words was not perfect. To be honest, at first, I didn't say anything. I pulled up a chair next to her bed, and simply sat with her as she scrolled through TikTok and intermittently turned her phone to show me a video she liked. Though her devastating question shook me to my core, I realized that for her, these words were likely not a revelation, but rather a daily reality. After a bit of time, she looked at me, slumped back in the bed, and said, “I just don't understand why everything is so messed up.” I sighed, locked eyes with her, and said one of the only things I knew to be true in that moment: “Yes, everything really is messed up.” Throughout our conversation, I listened; empathized; asked questions; and encouraged her to share how she was feeling. I held a space for her, one that I hope was safe. Upon further reflection, that may be what we are really called to do as pediatricians—not to be perfect communicators who always get it right, but to create and hold spaces where patients and families can come as they are, and know that they are seen, cared for, and fought for by their doctors. I still don't know if things are going to be okay for that 14-year-old girl. Or if I'll ever be fully comfortable discussing matters of race in the clinical setting. But I do know that I am committed to living the affirmation that Black lives matter, and this means making sure that my patients and families truly know that I am not just their doctor, but also their anti-racist ally in a fight for justice that marches on.
Thank you to Dr George Dalembert for his thoughtful review of this manuscript.
Financial statement: No financial relationships to disclose.
Published online: August 02, 2021
The author has no conflicts of interest to disclose.
Copyright © 2021 by Academic Pediatric Association