Author: Mercy Adetoye, MD, MS

In the winter of 2020, during the height of the COVID-19 pandemic, “Ava” presented via video visit for our appointment. Ava and I are similar in several ways. We are both Black women in our 30s, and neither of us have children, although I was starting to think about the possibility. As we wrapped up the appointment, she asked a seemingly routine question about the safety of the recently approved COVID-19 vaccines. I was acutely aware of my position as a trustworthy bearer of medical news, which I was afforded due to my racial congruence to the patient. I had given my response countless times and immediately launched into my spiel – the vaccine is safe, has been tested on many people and will protect you from a severe infection, hospitalization, ventilator or death.

She then asked a question that made me pause. She had heard that getting the vaccine could impact her future fertility. She worried it would be hard to get pregnant and that she would need assistance.

I did not expect this question, so it caught me off guard. I fell silent, and hesitated to respond. Several thoughts ran through my head at that moment. I had not specifically considered the implications of the vaccine on future fertility. Nor had I heard this discussed in my clinical circles or read data deterring women of childbearing age from getting the vaccine. Since the vaccines were so new, how could I definitively state that they would not impact her fertility? There was also an earned mistrust in medicine in the Black community. She and I are from a vulnerable population and she was already skeptical of the medical system. I did not want to do anything that would make her hesitate more. 

My pause continued, verging on uncomfortable silence. I finally informed her of my plans for vaccination, and that there was no data that I was aware of linking them to decreased fertility. I knew right away that she could sense my hesitation. Her body language and facial expressions clearly showed that she knew I was not as confident in that recommendation as I had been when initially discussing the vaccine. It was a fleeting moment, but I knew I had squandered the opportunity to provide sound guidance that would impact her decision about the vaccine. I felt disappointment and sadness. She declined the vaccine that day and continued to decline it until several family members fell ill and she wanted to travel.

When I reflect on that encounter, I cannot help but feel as though my hesitation somehow played a role in Ava delaying the vaccine. This was a moment lost, a space that clinicians will experience throughout their careers. It does not feel good and yet there are valid reasons why we have those pauses. I know as a trusted medical professional that there are real consequences when we hesitate and I do not take the responsibility lightly.

Dr. Adetoye is an Assistant Professor in the Department of Family Medicine at the University of Michigan. She attended medical school at Michigan State University and completed a residency in Family Medicine at the University of Michigan.

During intern year I introduced myself to Mr. Smith (name changed), an older white man.

“Hello I am Dr. Adetoye. I will be taking care of you during this hospital admission.”

When the attending led us back to the room for team rounds, Mr. Smith addressed me as a nurse.  The word hung in the air, but no one, including the white attending physician, addressed it. The intersectionality of being a woman and a woman of color meant that I was unsure which had triggered this comment, but I was uncomfortable either way.

I wanted to talk with someone who would understand. But in my large department, there were only two Black female physicians. I was a new intern, and I hesitated to burden them. I did not want to add to their ‘minority tax’ burden as the only Black woman on faculty. So, I kept it to myself.

In my last year of residency, I was working in a hospital in a predominantly white rural community. While writing patient notes, I overheard two men and a woman outside the room discussing whether it was appropriate for police to kneel on George Floyd’s neck when he was resisting arrest. They agreed it was, though the woman felt he should not have been allowed to die. When I stepped into the hallway, the two white security guards and white nurse that had been conversing stopped abruptly and watched me pass. I kept walking.

Down the hall, I passed a Black security guard and impulsively thanked him for being there. He said, “You are welcome, Doctor. Things are crazy out there. I will be here all night. If you need anything, do not hesitate to ask.” I thanked him again, slipped into my call room, and began to cry.

As the sole Black resident in this hospital, I was afraid and stunned. How could the staff that I relied on discuss the merits of murder? This time, I talked to my residency leadership. To my surprise and pleasure, they were concerned and responsive, and we worked on ways to improve the climate at the hospital.

We cannot assume that the day-to-day experience of seeing patients is uniform for all. We know there are better patient outcomes and patient satisfaction with racial/ethnic congruence between patients and clinicians. The programs that train young physicians must take the lead to create a safer and more equitable environment for all. This can be done by taking several steps:

1. Understand the communities where trainees work, identify potential challenges, and communicate these with trainees.
2. Make clear that discrimination will not be tolerated by the program.
3. Educate staff and faculty about these experiences and teach them to recognize and address microaggressions and support trainees.
4. Provide time for faculty of color to serve as mentors so minority trainees need not seek this on their own.
5. Institutionalize these policies so they are not dependent on the good will of one individual.

We can do better. Increasing medicine’s physician diversity and supporting trainees with these difficult experiences will prepare us all to better care for the world’s diverse patient population.

Dr. Adetoye is a Clinical Lecturer in the Department of Family Medicine at the University of Michigan. She attended medical school at Michigan State University and completed a residency in Family Medicine at the University of Michigan.

I had been building a therapeutic relationship with a patient over her last three visits. We bonded over being newly married, our mutual excitement about married life and the varying definitions of cleanliness partners could have in a relationship. During this visit, she had been experiencing abdominal discomfort and nausea. A simple test revealed she was pregnant. 

The patient looked stunned and began to cry softly. She had previously told me that she and her husband were struggling financially and were not planning to become pregnant for several years. We had discussed contraception at her last visit and she was considering several options.  She explained that she had been thinking seriously about contraception and was frustrated that she had not moved forward with an intrauterine device (IUD) prior to becoming pregnant. 

Through our previous interactions I had a sense that what she needed after receiving this news was time to process.  We initially sat in silence and I held her hand. I then stated that I was here to listen and help support her. I was not there to judge her and would give her all the information to make whatever choice was right for her.  At that moment I felt as though our therapeutic relationship, which initially started with a bond over shared lived experiences, had developed into a trusting patient/physician relationship.

She felt comfortable telling me that she wanted to terminate the pregnancy and would like an IUD placed after the procedure. I included the address for Planned Parenthood in her after-visit summary along with a note to my checkout staff to assist in scheduling the IUD placement appointment.

She later told me that when she went to check out, the clerk was adamant that she schedule a follow-up appointment for the IUD placement. This was an uncomfortable question for her and she felt pressured into explaining the need for an initial appointment at Planned Parenthood.  She felt embarrassed and upset.

I have reflected on this many times since it occurred. She trusted that I understood the sensitivity of the matter.  In my effort to be helpful and efficient, I feel damage was done to our relationship because of the way the checkout process unfolded.  I have thought about various ways in which I could have made this experience easier on her, including asking her to contact the clinic when she felt she was ready for contraception or adjusting my communication to my checkout staff to include a note about the  sensitive nature of this visit. Fortunately, the patient did come back for follow-up so we have a chance to continue to build our therapeutic relationship.

We all strive to do our best for the patients that we serve. As a trainee, I am constantly working on the therapeutic relationship which begins with trust.  I learn every day the impact that the small things that I do have on my patients. I am humbled in this endeavor and hope that the hard lessons are few.

Adetoye is a third-year resident in Family Medicine at Michigan Medicine, the University of Michigan Health System.