Systemic discrimination

by Dr. Renata M. Villela, MD, FRCPC 
Dr. Yusra Ahmad, MD, FRCPC 
Dr. Maryna Mammoliti, MD, FRCPC 

The COVID-19 pandemic has posed unprecedented challenges to our health-care system. Stress levels are exceptionally elevated across the board. Physicians have been called to action in novel ways and have had to quickly adapt to the seemingly ever-evolving landscape. Yet, to be effective caregivers, feeling safe – physically and emotionally/mentally – is paramount.   

Physician burnout springs from multiple sources, some of which have received considerable attention. An underrecognized area is discrimination on the basis of demographic factors such as gender, race, ethnicity, religion, sexual orientation, class and age. The intersectional nature of discrimination may be experienced both explicitly and implicitly. Unfortunately, it can be highly pervasive in all of its forms when various aspects are embedded in our current medical culture.  

Examples such as ostracism, devaluation and intimidation by colleagues or by patients and/or their families can be more at the forefront. Less obvious ones can include operating within a system that valorizes capitalistic markers of success (Example: billings and volumes of patients seen being prioritized over quality of care, connection, community and compassion). Sometimes, in a rush to appear more efficient and to make statistics tell a particular story, our institutions forget about the human beings involved.   

Many physicians from under-represented groups have heartbreaking stories of systemic discrimination at various stages in their careers. Discriminatory behaviours can manifest during peer or patient encounters. Sharing these experiences, even with fellow colleagues, is still considered taboo and can perpetuate feelings of invisibility and of voicelessness. This cycle only serves to perpetuate and to deepen the isolating impact of discrimination.  

Discrimination is distressing in any setting, but cuts even more deeply when it occurs in professional ones (Example: openly in the middle of the emergency department, in the classroom or in a meeting), with no true system to hold the perpetrators accountable for their behaviour. Widespread discrimination is disorienting, leading individuals to feel that the problem lies with them rather than in the structures that perpetuate these bigoted ideologies. The OMA’s recent and necessary work on gender pay gap inequities is a key step in unpacking some of the underlying forces at play.  

It is our duty to shine a light on deeper systemic discriminatory behaviours that have for so long contributed to physician burnout. This reflection would require us to admit, for example, that our health-care system is partially built on foreign-trained physicians. These physicians are often brought in and expected to work in a “less desirable” part of the country on a restricted/limited licence meant to keep these foreign-trained physicians in areas where Canadian graduates are scarce and are less inclined to work themselves. Yet, the mention of international medical graduates frequently evokes a certain amount of established dismissal and lesser-than attitude. It becomes then, unfortunately, a euphemistic and more acceptable way to express racism. Taking the time to consider these implicit biases can create discomfort.  

At the same time, with increased awareness occurring on a global scale, these crucial conversations feel long overdue.  Those from majority groups can consider how they could learn more about their blind spots and become allies who amplify rather than drown out the voices of their under-represented colleagues. 

Representation matters

Canada is often viewed as a country that prides itself on its diversity/inclusivity and physicians frequently serve as leaders in their communities. As a society, we have the power to decide whether that is an illusion or is rooted in reality. We can start to ask questions that have typically been in the background.  

• Why are there proportionately fewer Indigenous and Black physicians?  
• What are the systematic and very intentional barriers that keep us from having a physician body that is actually more reflective of our population?  
• How can we adequately and meaningfully serve the needs of all communities if we don’t train physicians who hail from these communities?  
• How do we prevent the rare few from burning out because they are overwhelmed by the volume of care they must provide to under-served populations, often in isolation, without adequate infrastructure support, while they face racism and discrimination themselves?   

There is a dearth of literature about these topics. Why do our systems favour well-worn research ideas that privilege the needs of only a portion of the population?   

The house of medicine is not supposed to be infected with these issues. We are trained to recognize, however, that there can be no solution without a problem being identified and clearly named. Pretending that racism, discrimination and structural inequities are not built into our entire health care system – from training to treatment to research – will prevent the achievement of meaningful, beneficial change across the spectrum. Let us instead harness this pandemic as a sea change for good and unleash a tidal wave of systematic reform.  

Dr. Renata M. Villela is Vice-Chair of the OMA Section on Psychiatry and also serves as President and Psychotherapy Initiative Lead for the Ontario Psychiatric Association. 

Dr. Yusra Ahmad is a psychiatrist in Toronto who is passionate about tackling the root causes of suffering and distress, including poverty, violence, gender inequality, racism and discrimination.  She has developed a faith-based group therapy program for the Muslim community entitled Mindfully Muslim.  

Dr. Maryna Mammoliti practices comprehensive psychiatry with a focus on psychotherapy, physician health, ADHD, developmental trauma and PTSD, and is Chair of the OMA Section on Psychiatry.