COMMENTARY

'It Was Like Seeing a Disparity Built Right Before My Eyes'

Jenna Lester, MD, as told to Usha Lee McFarling

Disclosures

October 19, 2020

Being told the operating room has already been cleaned. Being questioned by patients about where you went to medical school. Being asked for ID every time you enter your own hospital. Being told you don't look like a doctor. In a series of conversations with Medscape, Black physicians talk about racism they've faced in their training and their clinical work, the change they'd like to see, and how they're coping during this period of both pandemic and racial upheaval.

Dr Jenna Lester

So many of my fellow medical students came from families of doctors, long lines of White men who were doctors. For me it's similar but looks very different. My mother is a full professor of medicine and chair of the Department of Geriatrics at SUNY Upstate. My grandmother was one of the first Black nurse practitioners in New York. When I think about all the things they had to do to get to get where they are, I realize I'm representing a little bit more than just myself.

When my mom was in high school, they tried to put her in all vocational classes, like typing. My grandmother said, "No, she needs to be in Earth science." That family advocacy was so essential for both of us. Counselors at my high school in Syracuse, NY, were surprised when I wanted to discuss preparing for college while I was still a freshman. When I told them where I wanted to apply to college, they kept suggesting backup schools. My parents told me not to listen to them, and I went to Harvard. In college, my pre-med advisor told me to take time off before applying for medical school. My mother was on an admissions committee for medical school for many years and knew I was a strong candidate. I didn't take time off. I got into Brown's medical school ― and several other schools ― with a pretty substantial scholarship.

Brown was one of the few places where I didn't feel I was paddling upstream. I had tremendous support from deans and from many dermatology mentors. It was my father who first suggested I consider dermatology as a career; I became fascinated with the field during a summer research project as a first-year medical student. All the preconceived notions about dermatology – that it's only about acne and Botox – suggest that it wasn't something I would be interested in because I was focused on access to care and healthcare disparities and social justice. But I've learned that you don't have to be a primary care doctor to impact communities of color and that dermatology is about a lot more than acne and Botox. Because many dermatologists don't accept public insurance, there are disparities in care. In some parts of the country, patients can have wait times of months. Just by accepting more types of insurance, you are increasing access.

In 2018, I opened the Skin of Color Program at UCSF [University of California, San Francisco] to serve patients of color, who often do not get the best treatment because many dermatologists are not familiar with how to treat darker skin. In dermatology, we rely on textbooks and images for diagnoses. Eczema, for example, can look very different on darker skin. But so many of our textbooks and educational materials don't include images of what diseases look like on darker skin, so they can be hard to diagnose. I did a study recently on more than 100 images of COVID rashes in the medical literature and not a single one was of Black skin. Since COVID is disproportionally affecting people of color, it was like seeing a disparity built right before my eyes.

We need to diversify the editorial boards of our dermatology journals because they are in the position of power to control the academic conversation and diversify the work being published. The rest of us don't even know what is being submitted or why it's being rejected. We're now in a time where people's eyes are being opened to something they haven't been able to see before, but this problem has been obvious to many people in my field for decades.

I work and did my residency in San Francisco, which everyone thinks of as a liberal city. But even here, dealing with patients as a Black physician can be challenging. When I was an intern in Boston, I was rounding on patients one morning and a patient complimented me on what a delicious breakfast I had made for her. I said, "Can you please roll over? I need to listen to your lungs." With another patient, I was getting ready to pull his central line, and he said, "Oh, I would really much rather the doctor do that." I said, "Well, I'm the doctor, and I'm the only one here."

People always ask me, "Why do you wear your white coat?" I wear my white coat because otherwise no one will think I'm a doctor. Other doctors can go without their white coat and just wear their badge. When you're Black and you're a doctor, there is no badge big enough to make people realize you're a doctor.

These things are so deeply ingrained in ideas of who can do this job and who can't. One time when I walked into a room and someone said, "You're the doctor?" And I said, "Yup, we can be doctors now." People get really frazzled when you confront them, maybe because you're forcing them to confront the ignorance of some of their assumptions. Some doctors feel you can't say anything like that to a patient, but to me it's helpful to defuse the situation, because I still have to be their doctor and do a good job even after they've insulted me. When I can stick up for myself in these little ways, it helps me push past the moment and focus on their care. To me, the best answer to that kind of bigotry is to provide the best care possible.

I had a Black patient who had cutaneous sarcoidosis, which is a very deforming condition when on the skin and can be dangerous if it impacts other parts of the body. We were trying to start her on a medicine that required some fairly complex planning. Despite all this, she just wanted to tell me how she was so proud of me, how her granddaughter wanted to be a doctor, and asked if we could take a picture together to show her granddaughter. For many of my patients, they've never had a Black doctor. You can see it in their faces, the relief, even if they don't say anything. While I feel guilty spending any precious exam time talking about anything other than the patient, those moments really lift my spirits and remind me of why I'm doing this.

The way the pandemic is playing out is unfortunately not surprising to me. It's another example of the many inequities that exist in our country. I saw a picture of two girls sitting outside a Taco Bell to connect with Internet so they could attend remote school. It makes me think about my video visits with patients. You need stable Internet for those to not cut out every 5 seconds. And if you don't have an unlimited data plan, you could have a bill of thousands of dollars for a virtual visit. So, people with less resources are possibly less likely to engage in those services. And these are often the same people who are more likely to contract COVID and die from it. Many of my patients say, "Can you call me instead?" They don't have access to the Internet, or they can't connect.

Everything that's happening in the world is just making all the racism around us more obvious. These are conversations I've had with my family or with small groups of friends, but not something I've discussed in larger forums. It is a welcome change that we can have these conversations now since more people realize this is happening, and I guess that is progress. I hope some good can come out of it, some sustained change, but I must admit that I am somewhat skeptical. I already feel a waning urgency for many of the topics people were crusading for at the very beginning, like police reform. I hope people see what's going on and realize the urgency and the need to go beyond thoughts and prayers and institutional statements of solidarity and actually disrupt our systems of power.

As institutions try to make these changes, there is danger in overtaxing Black and Brown colleagues with the work. My biggest problem is that work on diversity, equity, and inclusion is not considered for academic promotion. There are so few full professors of dermatology in the country who are Black women. After seeing my mom promoted to full professor when I was in high school, that has been a goal of mine. So, to be asked to be on these committees that have questionable endurance, that you are not paid to be on, and on top of that, don't count toward the academic packet that will be considered for promotion is really not fair.

I would like to be able to do everything. I want to help every single medical student that wants to go into dermatology, especially those who are underrepresented in medicine. At the same time, I'm only one person, and I think I can have a bigger impact if I am able to have longevity in the academic environment. So, I've learned to say no. I think that is an important skill as a junior faculty person, to be able to say no to things you don't have the time to do, or don't have the bandwidth for, or are not comfortable doing. We can open up the opportunities for other people in the department who may not be racially concordant with the groups they are trying to help but have just as much, if not more, power to make change.

Jenna Lester, MD, is an assistant professor of dermatology at the UCSF School of Medicine. Lester comes from a medical family: Her grandmother Ruby Brangman was one of the first Black nurse practitioners in the state of New York, and her mother Sharon Brangman is a physician and professor of medicine who is chair of the Department of Geriatrics at SUNY Upstate Medical Center in Syracuse, where Lester grew up. Lester graduated from Harvard University in 2010 with a degree in sociology and from the Warren Alpert School of Medicine at Brown University in 2014. She completed her residency in dermatology at UCSF in 2018.

Usha Lee McFarling is an American science reporter who has written for The Los Angeles Times, The Boston Globe, STAT News, and the Knight Ridder Washington Bureau. In 2007 she won a Pulitzer Prize for Explanatory Reporting. Follow her on Twitter@ushamcfarling.

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