I Am Part of the Problem

Dinah Miller, MD

June 24, 2020

Race is not something I've spent that much time contemplating. I grew up in Elizabeth, N.J., a city of just over 100,000, in the 1970s and attended public schools where people came in all shapes and colors; diversity came with the turf, it wasn't something anyone needed to strive for.

My high school had more than 4,000 students with roughly even numbers of white, black, and Hispanic students. Armed police patrolled the halls, the thick aroma of weed settled in the stairwells and restrooms, girls brought their babies to school to show them off on half-days, and the "preppies" wore Fair Isle sweaters and played on the tennis team.

The school's campus was brand new and every lab, studio, and athletic amenity was state of the art; at the time, it was the most expensive public high school ever built in America. There were black teachers, librarians, and administrators, and segregation was something we read about in history books. I lived in a world of Technicolor and the Civil Rights movement of the 1960s, while still fresh in the minds of the adults, was something that showed up on black-and-white footage from another time.

My world became both wealthier and whiter when I went to college. There were minority students, but many of the black students at the University of Pennsylvania chose to live in the W.E.B. Du Bois College House.

People are often more comfortable being with others who share their backgrounds and this makes for an interesting conundrum: We all agree that desegregation is a good thing, but not everyone wishes to be told either where to go or not go, and there is an odd unbalance to creating a safe place for black students to be, one that both integrates and separates them from the larger community.

Perhaps all our lines get fuzzy — I recall when I was on the Maryland Psychiatric Society Women's Committee and a male psychiatrist signed up to join us — he was politely told that he could not join, but 20 years later, I'm wondering if it was okay to exclude a man who expressed interest in women's issues.

In medical school, we were taught to note a patient's age, race, and marital status, and we might learn that certain illnesses were more prevalent in certain populations, but there was no discussion of racial inequities in health care or anywhere else.

What was really different about the world back then, however, was what we didn't see and what we didn't talk about. Social media has opened a world where we can share our pain in the moment and we can band together to speak out against crimes and injustices in every realm. From the MeToo moments, to racially motivated police brutality. Cell phone cameras let us record and publicize these moments so the world can be the judge. George Floyd's sadistic murder by a police officer, as other officers stood by and watched 8 minutes and 46 seconds of torture, left us all triggered, distressed, angry, sad, and activated. Maybe now we can make real progress on a discussion that began in 1992 with the videotape of Rodney King's assault, a discussion we've had over and over to no avail.

Obviously, I have also been provoked by the events of the past weeks – like many Americans, I've paused to wonder how I can help the cause, both personally and as a psychiatrist. I would not normally write about racial topics — as a white woman I can listen, but I don't feel this pain in the same way as someone who has lived with a lifetime of discrimination and oppression. 

Dr. Lorenzo Norris and Dr. Brandon Newsome, two black psychiatrists, put out a special edition of the MDEdge Psychcast, "The fallout from George Floyd's death," and Dr. Norris noted that two of his white colleagues told him they thought of checking on him, but they didn't know what to say. Yes, I thought, that's exactly it, I don't know what to say and I worry that I might unintentionally say something that would worsen someone else's pain. Staying silent has always seemed to be the safest option. With this article, I'm moving from a place of comfort.

I started my career with a mix of private practice and community psychiatry. There were things I loved about working in a community clinic: the social aspects of being part of a team, seeing a full range of psychopathology, and treating patients in which the racial and ethnic demographics mirrored that of the community. There were things I didn't like, however. The pay was low, there were constant institutional requirements that were not relevant to the practice of psychiatry, and my relationship with the patients as their prescriber was much less fulfilling than the relationship I have with those I see for both psychotherapy and medication. Ultimately, the hospital shift to electronic medical records was the final distraction that caused me to leave community work.

Like roughly half of psychiatrists in private practice, I don't participate with commercial or public insurance plans. Early in my career, I worked in a group setting with billing secretaries, and I did participate with Blue Cross, but even with administrative help, nothing about this was easy, and when I left to do solo practice, I left insurance participation behind.

I love the autonomy of my career, I'm proud of the care I am able to give in this setting, and I don't miss the hassles. But I struggle with the fact that this is not the socially responsible thing to do — the out-of-pocket cost of care is higher and the effort of trying to get reimbursed falls to the patient. It means that most of the patients I see have the means to pay for care, none are impoverished or homeless, and while I work in a city that is 62% black, black patients make up a small percentage of my caseload.

I don't think I am unique in this; I would be shocked if any white private practice psychiatrist who specializes in psychotherapy is serving a racially proportionate population. As we start to embrace the idea that people don't neatly divide into being racist or not, and that bias affects us all, we must acknowledge that medical practices that don't support racially balanced access to care are part of the problem.

Amy R. Greensfelder, LMSW, is the executive director of Maryland's Pro Bono Counseling Project (PBCP), an organization that coordinates mental health professionals in private practice in Maryland to volunteer their services to those with limited resources. PBCP has found that 50% of those seeking services share that they are black or African American, and an additional 5% identify as multiracial.

Of all of those seeking care approximately 65% are black, Indigenous, or People of Color (BIPOC), and 14% are Latino/a/x/Hispanic. She says: "We see the racial composition of our clients as a direct demonstration of who is being left behind in the mental health system as it's currently set up, as BIPOC individuals are represented to a greater degree in our clients than they are in the general population of Maryland. During our intake interview, we provide an opportunity for clients to share if there are certain characteristics they are looking for in a therapist — often black clients share that they would prefer to be matched with a black therapist or a therapist who has received specific training on working with black clients."

While 13% of the American population is black, only 4% of physicians, 2% of psychiatrists, and 4% of psychologists are black. In her Psychology Today blog post, "Why African Americans Avoid Psychotherapy," Monnica T. Williams, PhD, notes: "Apprehension about clashing with the values or worldview of the clinician can cause ambivalence about seeking help, and this may be especially true for the many who believe that mental health treatment was designed by white people for white people."

Dr. Williams notes that black Americans also are less likely to seek care because of increased stigma and fear of judgment, concerns about the treatment process, and fears of being involuntarily hospitalized, cost and lack of insurance, and finally logistical issues with work, transportation, and family responsibilities.

George Floyd's tragic death has led us to a moment of crisis. It's my hope that the dialogue is now galvanized to make meaningful changes toward fixing racial inequities. I am part of the problem and these conversations need to include more equitable access to psychiatric care.

My thanks to Rachel Donabedian and Gina Henderson for their help with this article.

Dr. Miller is coauthor of "Committed: The Battle Over Involuntary Psychiatric Care" (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

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