Perspective

Dilemmas of Double Consciousness ¡ª On Being Black in Medicine

List of authors.
  • Ayana L. Langston, M.D.

Article

What do you do when everything changes? You know ¡ª the kind of moment when everything before it made complete sense and everything after it is totally unrecognizable?

Finding and maintaining one¡¯s own perspective are concepts that make perfect sense in theory but are incredibly difficult in practice, and they have taken me years to understand. The first time I revisited my elementary school as a high school sophomore, I looked around at how small the furniture was and thought, ¡°Wow, this place has really changed,¡± but I was the one who had changed. I remember the moment in my adolescence when I first saw my parents as actual people. They were raw and real with thoughts and dreams and lives that had existed long before I did and extended well beyond raising me. These shifts in perspective always hit me like a bolt of lightning, powering me with a newfound understanding of the world ¡ª like watching myself grow up before my own eyes.

It was a random day just like any other when I suddenly stopped being just a Black person in America. I looked around at the sea of white faces that seemed to fill every space I entered, and I realized for the first time that I was now a Black person in medicine. The distinction may not be clear to everyone, but these two existences have become vastly different realities in my life that, though they cannot be separated, have yet to find equilibrium. I know, both from my own pursuit of a medical education and from the numerous accounts of my Black colleagues and friends, that I am not alone in experiencing this internal conflict, but knowing that fact has not made it any easier to bear.

Until fairly recently, it was easier than one might think to minimize the effects of racism on my life. But the more I learned about the physiology of the human body, the more I was forced to confront the degradation of the Black body. The better I became at learning the algorithms for diagnosis, treatment, and delivery of health care, the more apparent it was that these algorithms were never meant to cure, heal, save, or protect any patient who looked like me.

I became frustrated and discouraged. As a Black woman physician in possession of all the knowledge that comes along with that title, I realized that you can do everything humanly possible to set yourself on an upward trajectory, but you can never outrun the truth of the past. No matter how many kale smoothies I drink or how many miles I run, I am still twice as likely as a White woman to die of heart disease, diabetes, or cancer and more than three times as likely to die in childbirth. As I look at my own family, I can¡¯t help but wonder how different our lives would be had we been born as White Americans.

My father, the heart of the Langston family, is the last living male family member of his generation. He is the only one left to look after his sisters, both older and younger, his nieces and nephews, and his own three daughters. His brothers, who in some ways I feel like I never really knew, departed this earth at various ages, afflicted by conditions ranging from diabetes to cancer to mental illness and suicide. But we do not discuss these matters. We continue to hold tight to family secrets that have taken and fractured the lives of people who had so much to share with the world.

And then there is me: youngest daughter born of my own generation. I came into this world almost a decade after my sister and what feels like an eternity too late to appreciate how different my family¡¯s lives once were. I look at old photos of my mother and father and feel like I am meeting them for the first time. I barely recognize my parents when they were first married, taking vacations and sharing holidays with extended family, or my sister, with bright eyes and thick hair, running around with cousins, sharing secrets and soaking up the wisdom of grandparents whom I would never know.

Part of me thinks that the unknown, the ¡°what if,¡± the ¡°what could have been¡± is one of the things that pushed me into a career in medicine. Could one Black doctor really have made all the difference in my family¡¯s lives? Is black skin so universally fatal that whiteness alone might have been enough to keep even one of my four grandparents alive long enough to meet me? If my grandmother had been born White, would her colon cancer have been caught before it was too late for a cure? What about my mother? Would she still be alive if she had been any race but Black? And what about me? Will my four academic degrees and nearly 20 years of formal education in science and medicine be enough to break this multigenerational cycle? These are the questions that keep me up at night. They envelop me ¡ª thoughts whizzing past like subway cars in a station.

And all these questions bring me back to my ultimate dilemma: How does one honor and protect the sanctity of one¡¯s own Blackness while also giving so much of oneself to a health care system that in many ways continues to dismiss, ignore, and mistreat Black people? How can either of my existences thrive while the other survives? Why does my professional development in medicine make it more difficult to overlook all the ways in which Black patients are discounted? Did my medical degree come with a pair of glasses that allow me to see injustice everywhere? Or is this recognition just another natural progression in my ever-shifting perspective? How could my pursuit of knowledge bring me to a place of such confusion? It¡¯s distracting, at times all-consuming, but mostly just exhausting. The more I dissect this conundrum, the more questions I have without answers.

The one thing I know for certain is that being Black in America is what I was born, but being Black in medicine is what I have chosen. I have dedicated years to learning to see the world from a clinician¡¯s point of view because of my Blackness, not despite it. Maybe that perspective, my perspective, will reveal something that has yet to be seen.

Maybe one day, the entirety of my humanity as a Black woman will flow easily among all the places and spaces I occupy. Maybe the lens through which I view the circumstances of my heritage will lift me higher rather than weigh me down. Maybe the world will begin accepting that the confines in which we place each other for our own comfort were never meant to contain or define all that we are. Until the maybes become definite, I will continue to straddle the line between who I am and who I want to be. Maybe my perspective isn¡¯t the only one that needs changing.

Funding and Disclosures

Disclosure forms provided by the author are available at NEJM.org.

This article was published on May 22, 2021, at NEJM.org.

Author Affiliations

From Walter Reed National Military Medical Center, Bethesda, MD.

Supplementary Material