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Discussing Race Really Touched a Nerve

November 9, 2021

Written by Clay Smith

CRT, CRRT, What?!

Yesterday’s post seemed to elicit some powerful emotions. We got several emails and a not so nice comment on the post (comment deleted*). It was a pretty sad day. Emergency medicine is a family. We are there for each other and for our patients 24/7/365. We are a team. Remember, the authors of the Annals of Emergency Medicine article are your colleagues and friends. Also, Eriny and I are your colleagues and friends. We are all on the same team. As I read the article linked above, it was clear that some of our EM team members are really hurting. When one part suffers, we all feel it. The commenter and several emails I received indicated that some readers thought critical race theory (CRT) was the motive behind the post yesterday, which is super funny! Both Eriny and I had to look up CRT. Was it like Continuous Renal replacement Therapy, Clinical Research Trial, Clay’s Really Thickheaded? I chose the editorial because I found it to be helpful and thought you would too. Eriny’s summary was thoughtful and amazing. In short, we thought it would benefit the readers of JF.

Important or not?

I think it’s more productive to just deal with what was said in the post rather than adding a variably-defined label like CRT to the mix.

The commenter on yesterday’s post said the following, which I found to be very sad:

“I can think of few less important things to do than the ‘advice’ in this article.”

What was the advice in yesterday’s post?  Was it important?  You decide.

Eight ways to be helpful

Here is my Spoon Feed version of yesterday’s post.

  • Educate yourself on race and racism.

  • Armed with understanding, humbly ask questions with the goal of being helpful.

  • Seek to help in constructive ways, with consent, when you see discrimination in the workplace.

  • Work to make our institutions equitable.

  • Don’t put all the burden of time and effort to promote equity on minority colleagues.

  • Ensure qualified, underrepresented students and applicants are considered for positions.

  • Consider how equity efforts, like founding a community clinic vs scoring an R01, might warrant promotion.

  • Have a plan to manage law enforcement personnel in the ED and how to handle concerns over use of excessive force.

Let’s take care of each other

This seems like good advice to me.  It also seems important. I have now read several differing definitions of CRT, but the above suggestions don’t seem to fit any of them. Rather, these sound like good, common sense ways to love our neighbors and consider others as more important than ourselves.

I don’t know about CRT, but I am definitely interested in learning how my friends and colleagues, who are different from me, see and feel the world around them.  And I am interested in doing what I can to make things right in my sphere of influence. I wanted the title of yesterday’s JournalFeed blog post to emphasize that we are friends and colleagues, and we are already allies.  But we all have a lot to learn to do things better.

And now the hard part, putting these principles into practice…

Clay Smith


* Anyone is free to comment on these blog posts. But I delete comments that are not civil or are not respectful. Critical is great – then we all learn. Uncivil…not so much. But there’s always Twitter if you want to rant.

18 thoughts on “Discussing Race Really Touched a Nerve

  • Compassion and empathy are the defining characteristics of our profession. While disagreement (often vigorous) is both healthy and essential to any field, offhand dismissal of our colleagues’ experiences is not. Keep doing great work here and keep touching nerves–your work is valued and appreciated by so many.


  • Hi folks,

    I fully support and care a lot about making an environment that is welcoming to every person regardless of what group they fall in to

    Some of us have issues however with CRT as an Avenue for achieving that. I think it is important to educate oneself on race and racism but also to educate oneself on CRT, what it is, who supports it. Many black people support it, many think it’s stupid.

    But don’t take my word for it

    My suggestion? Read the following books, some supportive and some critical of CRT and then make your own decision:
    White Fragility by Robin diangelo
    How to be antiracist by ibram kendi
    Intellectuals and race by Thomas sowell
    Woke racism by John mcwhorter
    Cynical theories by James Lindsay and Helen pluckrose

    And watch this short video for a good explanation of CRT: https://youtu.be/2rDu_VUpoJ8


  • Good morning,
    Im a Family Physician by training but have done a lot of ED work for the last 20+ years.
    One of the biggest differences in approach between FM and EM is due to practice setting. In a high acuity, rapid paced ED, it is difficult to apply the biopsychosocial model and racial determinants of health.

    However, as physicians, we have read how African-American people seem to have a much larger burden of disease than other patients. Much of this has to do with socioeconomic conditions. Many of these socioeconomic conditions are the result of racism and racist laws and policies.

    CRT provides an academic forum that analyzes how the concept of race has played a role in the history and structure of the USA.

    Much like climate change or telling an obese patient with CV risk factors that pizza may not be the best dietary choice, the truth is that certain conditions have led to the health inequalities we see today as it pertains to race.
    Unfortunately, it seems like, so much else nowadays, CRT has become a political weapon. This weaponization creates strong emotions and ‘reason is slave to the passions’.

    If a patient says something hurts, listen to them. I have been guilty of disregarding what patients say in order to fit their symptoms into my clinical scheme.
    Also remember race is not a monolith. There are different types of people within every category that do not necessarily agree with each other- that’s ok.

    It just seems that discussion of race tends to elicit aggressive and incivil reactions. My opinion is that many people have trouble confronting that certain groups have been mistreated purposefully and that mistreatment produced certain effects. This seems common in the group that historically did the mistreating.

    Even though many today have not engaged in KKK activities, owned slaves and may have friends that are of other races, this does not mean that the effects of the past are not present.

  • Racism touches nerves. Racism is, by definition, treating someone differently based upon superficial characteristics and a belief that they make one superior or inferior taken alone. The approach taken "Dear White Colleges in EM" is racist from go. It is tribalist and divisive. That is why the nerves flare. We have spent hundreds of years approaching a racially harmonious state, only to have it fractured intentionally by re-introducing differences. Great men from B.T. Washington, Fredrick Douglass, Lincoln, every abolitionist (both black and white) down to King are rolling in their graves. Further, this is decidedly NOT a medical issue. This is a social and largely economic (macro, not micro) one. Every time someone uses Kendi or DiAngelo or some other grifter on a MEDICAL website it cheapens our mission. Stay on track. Stick to medicine. And leave the racist grifters to ply their trade elsewhere.

    • I definitely hear what you’re saying and in a perfect world, we would not have to look at color/heritage/physical ability/socioeconomic status at all.

      However, our society has created groups that start at a serious disadvantage. And while it may seem like the correct path is to treat everyone equally, ignoring those systemic differences can be hurtful – maybe less so than overt racism, but deleterious nonetheless. What this article (and many others) argues is that we need to be intentional, not passive, about our understanding of these disadvantages and work actively to correct this, ESPECIALLY as physicians caring for these populations. We learn every day more and more how social determinants of health are as important, if not more so, for the well-being of our patients. Choosing to ignore these in the quest to remove race from the conversation is, in my opinion, misguided.

      MLK Jr. expressed this ideal much more eloquently than me:

      "First, I must confess that over the last few years I have been gravely disappointed with the white moderate. I have almost reached the regrettable conclusion that the Negro’s great
      stumbling block in the stride toward freedom is not the White Citizens Councillor or the Ku Klux Klanner but the white moderate who is more devoted to order than to justice; who prefers a negative peace which is the absence of tension to a positive peace which is the presence of justice; who constantly says, "I agree with you in the goal you seek, but I can’t agree with your methods of direct action"; who paternalistically feels that he can set the timetable for another man’s freedom; who lives by the myth of time; and who constantly advises the Negro to wait until a "more convenient season." Shallow understanding from people of good will is more frustrating than absolute misunderstanding from people of ill will. Lukewarm acceptance is much more bewildering than outright rejection. "

  • Let’s talk about two of the key topics here: antiracism and equity. First, "antiracism" is a deceptive term which can be used in many ways. Obviously, anti-racism defined as opposition to racism would be recognized by (essentially) all physicians as an ideal to pursue, and I believe we do try to oppose racism in our treatment of patients. However, this term also has a far more divisive and evil meaning when used by its key proponents, such as Ibram Kendi, who has spoken at national EM events and whose wife is promoted by EMRA. Under Kendi’s definition, to be anti-racist one must be anti-capitalist, anti-white, and willing to actively discriminate in order to correct "past discrimination", which he never bothers to actually quantify with evidence but rather with anecdotes. "Antiracism" as such is a political and divisive term with theoretical and Marxist roots which has no place in evidence-based medicine. Where active discrimination exists, we can eliminate it, but what Kendi wants is a complete demolition of our system in the name of fixing ill-defined past wrongs.

    Second, the related term "equity" essentially seeks to provide equal outcomes over equal opportunities. While there is a place for equity-based policies in many areas of life, when it comes to medical school/residency/occupation decisions based on "equity" this almost universally can be translated as "anti-white" and "anti-Asian" discrimination. This is already clearly seen in undergraduate and medical school acceptance rates, where underperforming students from non-Asian minority backgrounds are disproportionately accepted over more qualified candidates on the basis of race alone. While there are certainly situations where such a decision can be justified, in the medical field this lowering of standards is dangerous and harmful. We are currently seeing a massive shift in standards in our medical education in the name of equity, with objective measures such as MCAT and USMLE score rankings or class grades being replaced with pass/fail standards in order to improve diversity. Again, this is dangerous and insulting to the students of all backgrounds who are overlooked due to the color of their skin. It is not surprising that NP/PA career outlooks continue to improve while MDs stagnate, as those programs in general are increasing in academic rigor while medical school and residency programs regress in the name of equity.

    • Thank you for taking the time to write your thoughts. I wanted to share a few points in response that I hope are helpful.

      The article defined anti-racism as “an active effort to evaluate, change, and practice policies and behaviors that dismantle the racist structures that currently exist.” The request was to be active in opposing racism, rather than inaction. The article offers advice on how to do this; it is up to the readers to decide what is important to do within their sphere.

      Data from medical education suggest that scores and ranking alone do not make a successful doctor. The changes to pass/fail were intended to place emphasis on what matters to become a successful doctor. High scores are only predictors of high scores on a subsequent exam, but do not predict clinical acumen [1]. The USMLE was created to inform licensing decisions; it was not validated to be used in residency selection [2]. USMLE states that the decision to make Step 1 pass/fail was so that students can focus on their medical school curriculum and develop other competencies, rather than be hyperfocused on test prep resources [3]. School rankings have been abolished to improve medical student wellness because stress and burnout are high in this field [4]. There are other factors that are important in the application process, which include character, leadership, letters of recommendation, demonstrated clinical performance. A holistic review of applicants allows the field of medicine to respond to society’s needs [5].

      1. McGaghie, W. C., Cohen, E. R., & Wayne, D. B. (2011). Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions? Academic Medicine, 86(1), 48-52.
      2. Summary Report and Preliminary Recommendations from the Invitational Conference on USMLE Scoring (InCUS), March 11-12, 2019
      3. Murphy, B. (2020). USMLE Step 1 moves to pass-fail: Answers to 7 key questions. American Medical Association.
      4. Reed, D. A., Shanafelt, T. D., Satele, D. W., Power, D. V., Eacker, A., Harper, W., … & Dyrbye, L. N. (2011). Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multi-institutional study. Academic Medicine, 86(11), 1367-1373.
      5. Conrad, S. S., Addams, A. N., & Young, G. H. (2016). Holistic review in medical school admissions and selection: a strategic, mission-driven response to shifting societal needs. Academic Medicine, 91(11), 1472-1474.

      • Thank you for your reply.

        In response to your first point, the definition of anti-racism involving "racist structures that exist" is extremely vague and open to misuse and misinterpretation. Accusations of racism must be specific and directly address a particular individual or policy which can be shown to be racist. Otherwise, any apparently unequal outcome can be attributed to racism and lead to arbitrary systemic changes without any investigation into the actual underlying causes. For example, medical schools generally have a student body which overrepresents Jewish and white students while underrepresenting Blacks and Hispanics relative to the populations of their cities and/or states. Is this the result of systemic racism? Or does it reflect academic performance and personal choice? I agree in taking action against racism, but that must be done when and where racism is actually occurring, not when it is assumed. I 100% agree with the advice on confronting racism in the workplace, I just would advise caution using politicized terms such as "antiracism" or "systemic racism".

        I am quite familiar with the research on academic scores and their predictive validity, and I am in fact a proponent of medical education reform to eliminate the emphasis on USMLE which dominates the first two years of medical school. I also completely agree that scores and ranking alone do not make a successful doctor. With that being said, however, objective measures do provide a general indicator for intelligence and problem solving ability, and actually do predict clinical performance. Your single source mentioned here is 10 years old, uses a small sample size, and is mostly limited to procedural techniques. A number of more recent and more highly-powered peer-reviewed articles have provided evidence that higher scores preceding residency predict success not only on future exam scores but also on faculty reviews and clinical skills.

        With regards to your second source, I am not concerned with the "official" reason for eliminating it, but rather the popular opinions of many who have advocated for this change, especially in residency programs.

        For 3, I did not mention school rankings.

        For 4/5 I agree in a holistic approach, but first and foremost doctors must be intelligent and capable. Eliminate objective standards and you eliminate patient trust. The future of medicine will be in the hands of NPs if this trend continues.

        • Dave, I agree with you that we should not operate on assumptions and so I will continue to educate myself on race and racism to become a better ally as the article has suggested that I do. I hope you join me in doing the same. Thank you for having this dialogue.

          • To add to Dave’s comments, I read Eriny’s article. There is nothing substantive. It is the same collection of buzz-words on every left leaning talk show. As has been said many times Over the past 8-10 years, almost any American agrees with the sentiment. This issue is with the vague terminology used to club and alient people with opposing viewpoints. When someone does give a different viewpoint, that is used as proof of the original viewpoint, so it is an impossible debate. This is probably what is so frustrating for many people who read this. Then to have clay laugh in the bottom of the rebuttal as if the oposing viewpoints are childish similarly gives the same feeling. You may not agree, but obviously these are educated people with their own experience and thought process. That’s what this is all about right? Either way, disappointed that JF feels the need to be political and to grandstand. Sorry but its true.

          • Erin and Tom and Dave and others in this thread,
            I allow anonymous comments on this blog, because I can’t seem to make them work at all when I require an email, etc. Readers, please be aware. Dave, used an email that is obviously not real. Erin and Tom and some others, you have not identified yourselves. This is forum for civil discussion. It is mainly written for practicing clinicians. So far, I appreciate that your comments are on point and civil, which is why I have not deleted them. Plus I didn’t establish this as one of the ground rules. However, it is important for the JournalFeed readers to understand we have no idea who you are. If you are going to comment on this blog, you need to identify yourself. I am asking readers to please avoid commenting anonymously until I can figure out how to change my blog settings without breaking commenting altogether. We show clearly who writes each post and consider this a matter of integrity. Readers deserve to know who is writing what they read, and I apologize I am having this tech trouble. I will try to figure out how to change to no anonymous commenting. For now, we benefit from learning from each other and from the discussion. But if you’re not willing to stand behind your comments, should you be making them?

  • Clay, thank you for being brave enough to include this topic and the follow up post. We owe it to each other as colleagues to put in the work to understand each other and the perspectives and life experiences we bring with us. We owe it to our patients day in and day out to do the same. Better together, always.

  • Good afternoon! I would simply like to comment that Clay Smith is a beautiful man and that we should be grateful for this wonderful website and the lofty example Clay sets for us all. Keep it up!

  • IMO it’s not discussing race that’s touched a nerve, rather the context in which it was presented. At face value, all the concepts espoused in the article are clearly virtuous, however, as many have pointed at below, there is a SIGNIFICANT amount of semantic overload associated with many of the terms. The language used clearly point towards more "liberal" approaches to the problem of racism however it’s important to note that a large proportion of our population have different views (and no, not only whites and those of privilege). It would be nice if at least one of these general overview articles at least attempted to acknowledge the existence of more "conservative" viewpoints on racism in America and beyond but often they act is if there is only one clear problem and one clear solution.

What are your thoughts?