AMA Journal of Ethics^®

Kristen N. Pallok and David A. Ansell’s “Should Clinicians Be Activists?” highlights how physician activists risk retaliation from “economically and socially” privileged physician leaders and organizational leadership who “have been trained to comply” with structural inequity. We write as Black Yale medical faculty with personal and professional expertise in racial equity-focused advocacy. We reiterate the authors’ point: physician activists—skilled clinicians who challenge medical leadership and systems to dismantle racism—face retaliation because neither nondominant cultural authenticity nor equity-focused advocacy are systematically valued in, incorporated into, or safeguarded by current medical professionalism standards.

The Alpha Omega Alpha (AOA) Honor Society, medicine’s elitist society, membership in which is by nomination only, publishes a highly referenced monograph of medical professionalism standards.¹ Racism currently limits Black representation to 3.6% of medical school faculty members,² and AOA membership further limits Black representation by being preferentially offered to economically privileged, White physicians^3,4,5 who may be unattuned to and are invulnerable to racism. The monograph’s standards therefore center their dominant values and interests, even for minoritized and would-be activist physicians. For example, this 171-page monograph implores “a commitment to service, altruism, and advocacy”¹ yet never even mentions the words race, racism, prejudice, or equity. These standards generated by predominately White physicians vaguely praise advocacy while failing to intentionally and explicitly denounce health care’s own racism. Racial equity is literally omitted from medical professionalism, which places physicians who challenge health care’s structural and cultural racism outside the accepted boundaries of “professional” behavior. 

Whiteness pressures racially minoritized physicians to “code-switch”⁶ their mannerisms to minimize cultural deviations from White norms. Yet culturally authentic communication may explain the finding that Black men undergo more testing and preventive care when treated by another Black male doctor.⁷ For instance, as Black female physicians, we build rapport with our Black patients simply by showing up authentically with them, including shamelessly using slang and references to pop culture, explicitly naming racism, and sharing personal experiences—whatever it takes to connect! However, White physicians witnessing or supervising us Black doctors being culturally authentic may devalue our clinical excellence and penalize the culturally informed rapport we build with fellow Black people across the diaspora: whiteness accepts code-switching while rejecting authenticity. Worse, any physician who advocates for minoritized patients against leadership’s racist policies, practices, and norms risks retaliation by being labeled as “unprofessional.” Professionalism accusations against nonconforming physicians include being “resistant to feedback,” having “diminished capacity for self-improvement,” and being “unwilling to accept responsibility for their behavior and other’s perceptions of their behaviors.”¹ Personally speaking, the first author (C.B.) was remediated during her first residency program for claims levied against her “professionalism” using this exact coded language: resistance to feedback.⁸

Diverse, equity-minded faculty and trainees are recruited to dismantle racism. As Black faculty, we teach how adherence to the White normative professionalism standards that founded medical racism paradoxically stifles physician advocacy. To nonprivileged communities of color failed by medicine, perhaps physician activists are the truest medical professionals.