Recently, I decided to walk to work to get a bit of sunshine and take a break from sitting in endless virtual meetings. I live in Chicago¡¯s Hyde Park, a place that takes pride in its diversity. As I walked through the neighborhood, I saw a White colleague leaving her home about three blocks from the hospital. I was thrilled to see her, but as I approached, I noticed that she clutched her purse close to her and seemed to walk as far away from me on the sidewalk as possible. Just as she seemed about to cross the street to avoid passing me, I lowered my mask and identified myself. Her face was obscured by her own mask, but her body language conveyed her relief as she recognized that I was not a source of harm, and we exchanged pleasantries.
I am a 5¡¯2¡± middle-aged Black woman physician. Although I was wearing a (hospital-branded) mask, there is nothing about me that would seem dangerous to anyone, especially at 8:00 a.m. Yet in our world, any Black person is considered a threat until proven otherwise. Those of us who are Black, Indigenous, or People of Color (BIPOC) acknowledge this reality in a delicate game of de-escalation, which often requires code switching to survive in our surroundings.
¡°Code switching¡± is defined as shifting from the linguistic system of one language or dialect to that of another.1 As a sociological adaptation, code switching involves adjusting one¡¯s style of speech, appearance, behavior, and expression in ways that will optimize the comfort of others, in exchange for fair treatment, high-quality service, and employment opportunities.2
As a Black physician, I have found code switching essential to my success in academic medicine. This shifting comes naturally after years of practice at majority-White institutions. I switch from informal vernacular to formal language without even thinking. It allows me to make presentations at conferences or meetings that will be admired by colleagues as ¡°articulate.¡± Though I know it¡¯s meant as a compliment, I often wonder why it would come as a surprise to some people that a Black physician would be articulate after receiving 25 years of education. Just the same, I make sure to practice and script every presentation with an economy of words to minimize the risk of being perceived as less precise or less knowledgeable than my White peers.
Code switching also comes in handy with racially and ethnically concordant patients. At times when a BIPOC patient seems resistant to treatment plans reviewed by colleagues, I will intervene, sit down by the bedside, and find some point of commonality with the patient. Maybe we both have roots in Mississippi or maybe we grew up in the same Southside Chicago neighborhood. I take my time with the patient and use language that is as informative as that used by my colleague but less technical. Starting from a point of familiarity makes it easier to discuss tough decisions and reach informed consent. This use of code switching is what invigorates me every day as a physician practicing in an 80% Black community.
Of course, code switching can go poorly when used in the wrong circumstances ¡ª for instance, when White colleagues address me at work with a ¡°Hey, girlfriend¡± and a fist bump even though no other colleague is addressed this way. I always give a friendly smile and return the most formal salutations ¡ª ¡°Greetings, Doctor¡± and a handshake. Exaggeration begets exaggeration, and code switching works only when cultural appreciation doesn¡¯t become cultural appropriation.
Code switching back to my true self happens every evening when I leave my professional world and join my friends and family at home. It includes the nod of recognition that Black people give as we pass each other in the streets, and the way we recite our favorite rhythm-and-blues song phrases to acknowledge each other, greet each other with a hug and a handshake, or just let our natural hair down as we relax and take a deep breath.
Code switching is what allows us to continue to move forward when challenges feel insurmountable. It allows us to bear witness to racialized violence, police brutality, health inequities, and social injustice but still go to work each day with resilient fortitude. It helps us embrace the double consciousness that W.E.B. Du Bois described: ¡°It is a peculiar sensation, this double-consciousness, this sense of always looking at one¡¯s self through the eyes of others, of measuring one¡¯s soul by the tape of a world that looks on in amused contempt and pity. One ever feels his two-ness, an American, a Negro; two souls, two thoughts, two unreconciled strivings; two warring ideals in one dark body, whose dogged strength alone keeps it from being torn asunder.¡±3
Anita K. Blanchard, M.D.
University of Chicago, Chicago, IL
Funding and Disclosures
Disclosure forms provided by the author are available at NEJM.org.
This article was published on May 26, 2021, at NEJM.org.
1. Code-switching. Merriam-Webster (https://www.merriam-webster.com/dictionary/code-switching).
2. McCluney CL, Robotham K, Lee S, Smith R, Durkee M. The costs of code-switching. Harvard Business Review. November 15, 2019 (https://hbr.org/2019/11/the-costs-of-codeswitching).
3. Du Bois WEB. The Souls of Black Folk. Chicago: A.G. McClurg, 1903.