More Than Skin Deep: Building a Workforce Patients Can Trust

I was a fresh intern when my otolaryngology team was called to assess a patient with stridor and respiratory distress. We quickly identified her problem and determined she needed an urgent tracheostomy. But there was an issue: Despite being in an emergency department room full of physicians explaining why she needed this life-saving surgery, she did not want it.

As I examined her, I noticed her frailty. Her thin neck made anatomic landmarks clearly visible beneath her skin. Her chart told a story of surgeries and complications stretching back years. Her daughter was at her bedside, her face tight with worry, pleading with her mother to listen to the doctors. But my patient held herself with a fierce, quiet pride, firmly against surgery. In some ways, she seemed unreasonable, stating she would only do it if her primary care provider agreed. When logic stopped adding up, I knew the issue was not misunderstanding—it was trust, and the real reason went deeper.

My patient was Black. She was in a room with only white physicians and providers, aside from me. Though she could barely complete a sentence due to her respiratory decompensation, the discussions around her continued. I knew the rational explanations were futile, but still I stayed quiet. I assumed that, as an intern, I had nothing more to contribute beyond what my colleagues had already said. She then said in a remarkably clear voice, “What – does – he – think?”—her words broken by ragged inhalations. She pointed straight at me, and the room fell silent. In shock, I told her that if she were my grandmother, I would ask her to do it.

She immediately agreed to undergo surgery.

After her airway was secured, our team debriefed with her daughter. She told us that following her many past surgeries with complications, my patient had grown deeply distrustful of the medical system. Those complications were directly connected to the very condition that brought her to the hospital that day, furthering her disillusionment. Her hesitation was not misguided: Tracheostomy-related outcomes are universally poorer for Black patients, with Black patients facing higher complication and mortality rates (Laryngoscope. doi: 10.1002/lary.27500).

The very procedure we were asking her to undergo was therefore not benign, and if anything, the data showed that the odds continued to be stacked against her. In a medical system she believed had wronged her time and time again, she just wanted to hear from someone she trusted. For her, that meant someone like her primary care provider—or in this instance, someone she believed would not put her through another procedure that would cause unnecessary pain. In that critical moment, when no one else in the room had earned her trust, that person was me.

Her experience reflects a broader reality in medicine. Race is a social construct, but its consequences shape who receives access to care and fair treatment. We often treat race as a “risk factor” for disease. In truth, race reflects the societal factors our patients navigate every day, including the effects of racism itself. Beyond tracheostomy placement, otolaryngology patients face racial disparities in head and neck cancer morbidity and mortality, referral and access to hearing surgery, differential exposure to infectious etiologies such as pharyngitis, sinusitis, or otitis media, and inferior treatment of sleep apnea, among many others (Curr Otorhinolaryngol Rep. doi:10.1007/ s40136-023-00459-0). But statistics on racial disparities in our system feel different when you stand at the bedside of someone who has suffered the consequences of that system.

This patient experience reinforced not only the need for diversity in our field but also the importance of specific training for our workforce that empowers us to address healthcare disparities and combat racism in medicine. In medical school, I realized how little of this history we were explicitly taught, and how much of it I had to seek on my own. My curriculum was missing the critical context of racial health inequities, including the history of how our medical system has been built on various racist research practices and other biased and misinformed principles. Together with my colleagues, we worked to change our medical school curriculum so that every student would have this necessary education (Acad Med. doi:10.1097/ ACM.0000000000004531).

Now that I am an otolaryngologist in training, I see this need within our field. Otolaryngology still has progress to make in closing the gap in the recruitment of trainees who are underrepresented in medicine so that our workforce reflects the diverse backgrounds of the patients we serve. Once we achieve a representative workforce, from the trainee to leadership level, conversations like the ones we had with my patient may naturally be easier. Equity in recruitment and promotion is only part of the solution, however. The root causes of healthcare disparities in our field are multifactorial, and as physicians, we often feel like we have little control outside of advocacy to address the larger socioeconomic factors that perpetuate these disparities. Yet we do play an individual role in the everyday care we provide to our patients.

There is an opportunity for each of us, regardless of race or skin color, to communicate more effectively and more fully address the needs of our patients from diverse backgrounds. I have learned how much it matters to understand the harm a patient has lived through, the biases we all carry, and the history that shapes even a simple conversation. That moment with my patient reminds me that while our training teaches us how to diagnose and treat disease, it rarely teaches us how those systems shape our patients’ lives. We must pay attention to the larger story in the room, know the history that brought us to this moment, and truly listen— beyond the words a patient speaks. These are interpersonal, structural, and equity-focused competencies that can, and should, be taught. The more intention we bring to this, the more we dissolve the barriers that separate the patient from the physician.

Topics such as racism in medicine, healthcare disparities, and structural determinants of health are critical to integrate into resident training and continuing medical education efforts for established otolaryngologists. In fact, there has been a call to action in this regard at the graduate medical education level. The strategies identified for improvement of our systems include incorporating inclusive pedagogy and structural competency into education, building a diverse and inclusive learning environment, and increasing community engagement (Acad Med. doi:10.1097/ACM.0000000000004664). Our charge is clear, yet we are currently failing to meet it. A minority of otolaryngology residency programs have quality curricula on health disparities, with the described barriers to development being insufficient time, limited perceived ability, and faculty disinterest (OTO Open. doi:10.1002/ oto2.148).

We have a duty to meet the needs of our patients, and the solutions to the healthcare disparities they face should be both varied and nuanced. The first step in addressing these issues is to recognize them, and then we can begin to rectify them with the individual patients we sit across from in our clinics, emergency departments, and hospitals. With the proper training, we can do more to rise to the call to action and move the needle forward, patient by patient.

My patient was willing to die over her mistrust of our medical system, and she was a living example of how the disparities we discuss affect the real patients we care for. I learned that knowledge and skill are only a part of the essential training I need. My experience, history, and identity are things I carry with me, too, and things I should bring into the care of my patients. Sometimes, those things are what a patient needs from their physician the most.

I am humbled that my patient placed her trust in me when she had every reason not to. That trust may have saved her life that day, but it also left me with a responsibility I am still learning how to honor. It is my reminder of the work that remains, both for me and for the future of our field.

Ajay S. Nathan, MD, MS, is an otolaryngology– head and neck surgery resident at the University of Connecticut in Storrs Mansfield, Conn. His interests include health equity, medical education, and patient-centered communication in surgical care.