The grotesque racism that we witnessed with the killing of George Floyd has made it clear, again, that there is an enormous amount of work to be done in this country. The outcry has been tremendous, but the hardest work is yet to come. Structural racism penetrates our everyday lives and won’t be dismantled until it is widely seen. As an emergency room doctor, let me tell you what I see every day.

I decided to become a doctor when I was a small child, shortly after my family moved to the United States from Jamaica. There were no physicians in my family. I don’t have a friend or relative who triumphed over a serious illness because of the care of a physician. I only saw my doctor, a white man, once a year for a checkup and vaccines. At the time, I had no idea that only 2 percent of physicians are black women.

Tunnel vision took me through school, undergrad, medical school and public health school. I then completed a residency and confirmed that emergency medicine is the distilled essence of my childhood idea of medicine. I see anyone who enters the building and wants help. I’ve had patients who were minutes old and patients who are over 100 — every part of the socioeconomic spectrum, every walk of life.

I don’t choose my patients and they don’t choose me. I’m just the one who happens to be there when they show up — even in the middle of the night with a shoulder dislocation that forced one patient to reveal the four-inch swastika between his shoulder blades.

I start every patient encounter the same way. I’m wearing blue scrubs and a long white coat with my name embroidered on it, and I visibly rub in hand sanitizer so they know I’m careful about spreading germs. A stethoscope hangs on a clip from my scrub pants and I have a name tag on my chest with my photo and a second bright orange tag with DOCTOR in all caps. I say, “Hello, I’m Dr. Ennis, I’m the emergency physician. What brings you here today?” Then I pause. Deliberately.

Unless I’ve seen the patient before, there’s always a moment where things shift. The first thing they saw when I walked in the room was a black woman with natural hair. I wait a moment while they reconcile the cognitive dissonance of who they see in front of them with what they just heard so we can get to the reason they came. For most people, the pause is enough.

But some folks need a bit more help to move forward. There are a few questions I have been asked repeatedly over the years and I have a lighthearted canned response for most of them. The most common is “Where are you from?

I reply with a disarming grin and then spout off: “I was born in Jamaica, grew up outside of Philadelphia and went to school up and down the Northeast.

Sometimes we can get to the medical emergency that brought them in, but sometimes there’s a follow-up question. “Oh! Where did you go to school?”

So I list: “Undergrad at Brown, med school at NYU, my masters in public health was at Harvard and residency training was at MGH and the Brigham.”

That’s enough to satisfy most people.

Sometimes, though, people ignore or cut off the introduction and respond to their own internal dialogue. Every now and then, a patient borrows a hospital phone from a nurse in the emergency department. As I walked in to meet a new patient, I once heard: “Ah! Here’s the phone girl!

A recent patient let me get through the introductory ritual and then said, “You don’t look like a doctor.”

I replied, “What does a doctor look like?”

“Hmmm, taller,” he said.

“Well, sir, I’m 5’8” so I’m not sure how much taller I need to be,” I replied. “In any case, can we move on?”

A favorite of mine is “You look too young to be a doctor.”

In my mind, I say, “Black don’t crack,” but I just smile and say thank you.

Though melanin and genetics may be giving me an edge on the game of visible aging, I’m pretty sure these questions are based on that which is never said.

Once, as I walked past a patient’s room, I heard the family berating their nurse, demanding to be seen by a doctor because they had been waiting for hours. I popped in to reassure them that I was, in fact, their doctor. I’d already been in the room several times. I had done a rectal exam. All I could think was, “Why would you let me do that if you didn’t think I was your doctor?”

For the past year or so, I’ve started to share these moments with colleagues in real time. Most of my physician colleagues in the emergency department are white men, and sadly, these are issues that most of them have never had to deal with — not even once.

So much of my training, both formal and otherwise, has focused on relieving the discomfort of others. People come to me when they are injured or in pain, and my imperative is to relieve discomfort in those moments. That is unquestionable. In a nonclinical setting, however, I still tend toward relieving the discomfort of others, even as it means increasing or ignoring my own.

A few months ago, I had a patient who was absolutely lovely. There was no drama about me being her doctor. She was there with family members and they were equally delightful. I’d been in and out of the room several times, shared test results, a diagnosis and the good news that she wouldn’t stay in the hospital overnight. As is my routine, I asked if there were any other questions I could answer.

She looked at me and said: “Are you a U.S. citizen?

That was a new one for me.

I said, “Yes I am, are you a U.S. citizen?”

She looked a bit flustered and said, “Of course I am.”

I replied, “Great, well, I hope you have a wonderful day.”

At that point, my job was no longer to make her feel comfortable. I had done that job. So I pivoted and checked her bias. I now find myself less inclined to turn a blind eye to these moments. Many people, including my colleagues, have no idea of the cumulative impact of these interactions. For the patient, it was one conversation. For me, it was the third slight that day. Medicine is challenging enough, especially now with covid-19, without having to expend so much mental energy wondering when I’m going to be blindsided by bias.

Even as people across this country protest brutality and racism, there is fear among my white colleagues of how to approach the subject in our workplace. On a recent day, we ripped off the scab and over 100 people knelt for 8 minutes 46 seconds in front of my hospital in honor of George Floyd. A patient and I cried together.

After I’d finished addressing his medical issues, the patient, who is white, looked at me with incredible tenderness and his eyes filled with tears. He said he was sorry for what was happening in our country and the cancer of racism that has led us here. That was an incredible moment for both of us, and I hope the first step of many to come.

Khama Ennis is chief of emergency medicine at Cooley Dickinson Hospital in Massachusetts.

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