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Diversity Matters

Diversity Matters

Code-Switching as an EM Survival Tactic

Brown, Italo M. MD. MPH

doi: 10.1097/01.EEM.0000731740.47326.45
    code-switching, racism

    Physicians from underrepresented minorities (URM) are disproportionately affected by the lack of safe spaces in medicine. This is largely due to a comfort dynamic rooted in white male heteronormativity. In fact, the impulse to fit in is so significant that many URM physicians have adopted code-switching as a survival tactic.

    Code-switching is when an individual adjusts his speech, behavior, appearance, or expression to optimize the comfort of others. This lexicon (one that involves alternate language, dialect, gestures, phraseology, etc.) is developed under a form of duress. Without it, hopes of garnering equal treatment, quality service, upward mobility, or notable employment opportunities may be extinguished. Some have touted this as an asset or a proverbial feather-in-cap, but a true stance of equity demands that we label this appropriately. Code-switching is a pathological response to the stimuli of systemic and structural racism.

    This often means URM physicians must contort their identities just to ensure the best chances at conventional success in a given field. The social pressures to assimilate in order to advance are abundant and tend to be reinforced through our daily microinteractions. Consider these:

    • Colloquial use of “bro,” which is a nod to modern fraternity culture.
    • In-conversation voice adjustments to match a colleague's vocal tone.
    • Inappropriate humor used as a bridge in small talk.

    I'll never forget when a surgeon of color pulled me aside beyond the earshot of other providers just to ask me a question: “How did you make it this far with dreadlocks? If I had them, I'd have to kiss my career goodbye.” This is an example of how self-conscious URM physicians have to be to excel in the disciplines we love.

    Comfort v. Identity

    I admit that I have had to code-switch throughout my career. For instance, though I am naturally a sports enthusiast, there was a period in my career where I paid special attention to NHL hockey. As a Black man from California, hockey was never on my radar, but I knew many of my colleagues followed the sport closely.

    To better assimilate, I watched Barry Melrose on SportsCenter, and I applied my newfound hockey knowledge when the time came. Almost immediately, I was initiated into the fold and included in casual, non-sports workplace conversations. In hindsight, the desire to preserve my team's comfort dynamic outweighed the desire to uphold my own identity.

    Put another way, one could suggest that EPs practice code-switching (or a similar adaptation), particularly the ability to speak the language of other disciplines, to better navigate the consult world. When faced with eye complaints, we describe acuity and chambers and throw around phrases like “cell” and “flare.” When we speak to our obstetrics colleagues, we begin with gravida and para, provide last menstrual period dates, and convey if the cervical os is open or closed. But adopting the languages of other medical specialties does not infringe on our identities as physicians while code-switching directly suppresses an individual's personhood.

    Identity Suppression

    The key difference between this bridging of technical jargon and the URM physician changing his speech down to the octave is in the consequences. If an EP struggles to convey neurological signs to a consultant to aid in diagnosis, frankly, it is punitive; there is time and space to learn and develop effective communication.

    But if a URM physician fails to showcase enough affinity for the same culinary styles and films or share the same idiosyncrasies from educational institutions as the majority, he will virtually be labeled an outsider. Outsiders are denied trust and opportunity, which in medicine are inextricably linked to growth and advancement. Suffice it to say, if the goal within emergency medicine is to be antiracist, then we must acknowledge that there is more to professionalism than looking, talking, sounding, and parroting the dominant culture.

    Consider the possibility that we are dampening our collective success by expecting those among us from other cultural backgrounds to first demonstrate their social acuity and willingness to conform before being deemed worthy. Even more, think about the amount of talent, effort, and energy that URM physicians devote toward blending in. Could it be better spent launching medicine and emergency medicine to their next levels?

    Every uncomfortable article and conversation we have inches our specialty closer toward antiracism. But even the idea of comfort is inherently flawed. Specifically, we need to take a critical inventory of who defines and establishes the standard of comfort among clinicians. Historically, medical culture rewards those who stand out academically but blend in professionally, a practice emphasized across the hierarchy of emergency medicine.

    For URM physicians, this often translates into identity suppression. Furthermore, the concept of basic freedom remains at the heart of most systemic and structural issues we seek to correct. Our failure to unpack comfort is essentially why we struggle to identify workspaces as cultural safe spaces. To break this code, we must address the issue head on.

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    Dr. Brownis an emergency physician and an assistant professor in social emergency medicine at Stanford Hospital. He is also the chief impact officer of T.R.A.P. Medicine, a barbershop-based wellness initiative that leverages the cultural capital of barbershops to address the physical and emotional health of black men and boys. He also served with the ABC News Medical Unit, and has contributed health equity and wellness pieces to The New York Times, USA Today, GQ, and The Root. Follow him on Twitter@gr8vision. Read his past articles at

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