Why must Black, Indigenous, racialized women and non-binary physicians endure racist harm in the workplace in silence and isolation?

Two toxic workplaces, almost a decade apart. Same person affected-a racialized woman physician but at different stages of her career. Two different provinces, two different institutions, two different chains of command, two different policies and procedures to navigate. Two different decisions about whether to submit a formal complaint for gendered racism (and ageism) for harmful behaviour by different white male physicians. Two different decisions and experiences once initial informal complaints made. Same outcome: No justice, no acknowledgement of the harm endured, no accountability. While I may have made the decisions to leave both of these workplaces, they were not actual choices I had due to the great harm that I endured. I still suffer from the trauma, and physical and psychological ramifications of ongoing injustice that I endured in both of these workplaces. My family has also endured the effects alongside me.

The most recent ordeal dragged on over the last 12 months until I excised myself from the horrendously toxic situation. As I’m left picking up the pieces again, doing everything I can to bring down my blood pressure and stress hormone levels, and healing from what was a traumatizing formal complaint process, I can’t help but ask, if I truly feel that both experiences have left me with the same outcome of feeling unheard, unseen, unacknowledged and without justice with regards to my harmful experiences in the workplace with other physicians, then what real options do racialized (Black, Indigenous, Asian, and other Persons of Colour) women and non-binary persons in medicine have when disrespect, gendered racism and other mistreatment occurs in the workplace? My two complaints were specific to certain male physicians and incidences that crossed the line for me. There have been countless covert and overt racist aggressions I’ve endured over the 23 years of training and my career in medicine. I could fill pages with stories of unwanted touching, or of being told to my face that I was a “diversity hire”, that “Asians don’t experience racism, so be quiet”, that my “English is so good”, and that “my people” are responsible for the pandemic because of our “disgusting” eating habits by colleagues and patients. I have been mistaken innumerable times by patients and staff members to be a member of the housekeeping or food services staff in to collect dinner trays over my entire career. I know that I’m not alone in suffering persistent racism throughout my years in medicine. A survey of physicians in Alberta (one of the provinces I’ve trained and worked in for many years) that was published last month, showed that over 75% of cisgender BIPOC women physicians surveyed had experienced harassment and discrimination. 74% of the small number of physicians who reported such workplace harassment and discrimination were unsatisfied with the outcome due to retaliation or lack of satisfactory outcome. While I didn’t complete this survey, these statistics completely resonate with my experiences. The overtly violent and racist comments published in the report by white physicians, our colleagues, shows beyond any possible shadow of a doubt, the truly toxic and racist culture that people like me must endure in our careers.

With over 50% of Canadian physicians reporting burnout two years into the pandemic, I am stating clearly that without addressing the rampant racism experienced by Black, Indigenous and racialized physicians (most especially women and non-binary), along with all healthcare workers and patients, there will be no improved wellness for us. Wellness is more than the burnout that racialized women and non-binary physicians are at increased risk for; it includes understanding and addressing the fact that there are physiological impacts on racialized physicians’ health from being subjected to ongoing racial injustice in the healthcare system.

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The first time I tried to put in a formal complaint for two white male physicians, who I will call “Jeff” and “Bob”, I was told by the Department Chair that I should be warned of how hard a formal complaint process would be for me and my young family. “Is this really what you want or need right now, Amy? You know it will simply become a ‘he said, she said’ situation.”

When I pushed back that I had a paper trail for “Jeff’s” years-long mistreatment of me, and that the egregious way in which “Bob” treated me was witnessed by several other department members, the Chair responded, “No, that’s not how it works.” Then he went on to say, “Amy, you have to understand that they feel threatened by you. They see you as a young whippersnapper, 20-30 years younger than them and you make them look bad with how productive you are.” What was alluded to in that conversation was that as an Asian woman leader, I was just expected to “work so hard” but not do it in a way that “threatened” anyone else. I wasn’t to make any waves. I was to just do the work demanded of me and be quiet. I was supposed to know there was an unspoken societal agreement in that my age, identity and productivity would be seen by others as tacit justification of their bullying of me. The Chair would not support my request for a formal complaint; he would “sit it out” if it came to that.

I resigned and left that position six months after that conversation. I gave up my hard-earned tenure achieved at age 35 at that university after years of enduring this toxicity upheld by so many complicit colleagues, and for which there was no end in sight. It took me several years to process, unpack and undo the belief that I was the problem, as they had made me feel. Truthfully, it wasn’t until “Jeff” had a very public run-in with the law that exposed his true lack of a moral compass, could I even start to believe that maybe I wasn’t at fault for having to leave that institution.

Fast forward several years and another leadership position in another province within another institution. My past experiences had taught me a tremendous amount, and put me on the alert for any disrespect. In feminist scholar Sara Ahmed’s book, Complaint!, she writes, “You can’t go back to the person you were before the complaint, you can’t unsee what you come to see through complaint…being able to see what is going on, to see more, is also to see what you did not see before (Pg 29).” In addition to not being able to unsee gendered racism and disrespect, I now had even more years of experience and expertise under my belt. I was not going to tolerate ongoing gendered racist undermining of my work and leadership 17 years into my career. As part of my ongoing anti-racist and anti-oppressive praxis, I actively call out power differentials and the “elephants in the room” when I perceive conflict and tensions between groups that must work together in an effort to actively address them and find workable solutions. At this new workplace, I was told at first that they appreciated my ability to call out power dynamics that were affecting working relationships and peoples’ work (which was ultimately the care of patients and families). But they became more resistant to address these concerns as I kept bringing it up. It only took six months of subtle othering and subversion as the only racialized physician (and leader) in this group for a more overt gendered racist attack to occur that challenged my leadership in a public manner. Let’s call this white male physician, “Bill”. It was immediately apparent as the only racialized physician in this group, that no one understood the gendered racist impact “Bill’s” comments had had on me, or that I was being punished by him for not conforming to the racist stereotypes of the subservient Asian woman who is not to take a stand. The people who could have intervened on my behalf were immobilized by their own white fragility. When I expressed my harm that had been witnessed and unconfronted by the other white physicians, I got the “Oh, I’m sure he didn’t mean that”, and “No, we’re not racist, we’re (colour-blind) nice physicians” types of reactions, including from the leaders who would receive the complaint. I had no choice but to proceed with the formal complaint process against “Bill” to be seen and heard; this process was horrendous and traumatized me even more.

There were so many points in this formal process where I endured even more harm and that exacerbated the threat I felt in my workplace: a) the notion that both the complainant (me) and the respondent were seen as on equal footing as colleagues, completely disregarding the societal power differential of a white male physician with that of an Asian woman physician, in a virtual face-to-face alternative dispute resolution attempt where he could be allowed to exert his power and privilege over me without any restraint, b) the stance of “neutrality” by the institution in adjudicating this complaint of gendered racist harm, and c) the eight months of silencing during the investigation that fostered the ostracizing of me in my workplace with the whispers of my being “difficult” and “unwell” by my other (white) colleagues, while all the benefit of the doubt was given to “Bill”. The worst part was that my complaint was only handled by various white people, none of whom had either any understanding or lived expertise to understand racism. The institution used a colonial legal framework and lawyers to determine whether I was treated differently than a white man, which is missing the point entirely. In making my complaint, I was not seeking to be treated the same as a white man (equality not yet achieved in society); I was seeking to be heard and seen as an individual with an incredibly different lived experience for which my psychological safety is never assured not only in spaces of vast whiteness, but also within the colonial healthcare system and society in Canada. Recognition that I would have different needs for how to be treated is, in fact, the equity I was seeking as a person who has less societal and systemic power and privilege than my white colleagues. We have not yet achieved equality in society and must stop deluding ourselves that treating everyone the same is appropriate. I was morally injured and mentally exhausted throughout the complaint process. I have come to recognize that the entire complaint process itself, and subsequent ostracization I endured for putting in a complaint were an extension of the harassment for which I complained. This in it of itself is the goal of harassment: to tire out and inflict weariness through the repetition of trying experiences (Ahmed 2021).

So to answer my own question that I had at the outset of this piece, I can honestly say that neither option was helpful to me as a racialized woman physician leader. Neither option gave me any validation, acknowledgement, or any accountability for bad behaviour. Both options caused further trauma and harm that has affected my well-being and that of my family over the years. My well-being is affected not “only” by the psychological ramifications and burnout I suffered through this mistreatment, but the physical effects that coping with oppression at work have due to increased stress and inflammatory responses (Marya and Patel 2021). There has been absolutely no justice for what I endured.

The sad truth is that there are no good choices to seek acknowledgement of harm, receive any accountability for harm, or have any systemic changes made that would make institutions less harmful for racialized women and non-binary persons in healthcare to navigate. This is the despairing reality of the patriarchal, colonial, and racist medical culture in North America, and that of the Western world. I also live and work with disabilities due to ongoing neurological effects from surviving a near-death rollover motor vehicle collision that punctured my lung, broke several ribs and crushed my backbone (vertebrae) in four places when I was a resident physician. I haven’t, however, even touched how the unwillingness of call groups to accommodate such disabilities in call schedules has resulted in even more oppression for me.

How is this acceptable? The ongoing pervasive nature of systemic racism means that the medical profession is not adequately supporting racialized women and non-binary persons within the profession. This also elucidates that if colleagues within the medical profession are subjected to ongoing racism, the racist harm that our profession causes the patients and families we serve to suffer is immense. The racialized physicians who are harmed within the profession are arguably those who would be most acutely aware of the need for cultural safety for patients and families. But, if we are not supported and holistically healthy as professionals, how can we work to ensure safety for our patients in a sustainable manner?

Another quote from the book, Complaint!, resonates with me, “What I learned about institutions from…a complaint led me to leave; at the time it did not feel like a choice but like what I had to do.” If “complaints are more likely to be received well when they are made by those with more power” (Ahmed 2021 Pg 38), then how do we compel complaint systems (both informal and formal) to rectify this ongoing power imbalance that only serves to further harm racialized women/non-binary people, and others from intersectional oppressed backgrounds who have the courage to make a complaint?

We must overhaul the colonial complaint system to better support and protect racialized women/non-binary people in medicine. Physician wellness will be the most critical priority we have going forward as we continue through this pandemic to a post-pandemic recovery of the physician workforce for years to come. For racialized women and non-binary physicians, addressing gendered racism in medicine will be the wellness issue that must be tackled if there’s any hope to curb the burnout amongst us. We must have systems work for those with less societal and institutional power by virtue of their social location and oppression. The system must work for those who must fight daily to be seen, heard, and respected. We do not have the privilege of having existed as a white male in society who has always been afforded the benefit of the doubt. We continue in our careers to be denied the same privileges bestowed to white male physicians and to some degree, white women physicians, in our profession. We must acknowledge this hard truth. While white male physicians have been emboldened to take up space by being praised and rewarded for it, racialized women physicians are punished for daring to take up space, even when they have the expertise and job title with responsibilities that requires speaking up and making decisions. We must acknowledge that medicine is not immune to the systemic systems of oppression pervasive in society. To better support racialized women and non-binary physicians, we must have a safe and effective accountability system to submit complaints that has the principles of equity as its foundation.

The system must start out with believing victims and those with intersectional identities that are oppressed who have the courage to submit a complaint about racism or oppression. The system currently treats the person who has been oppressively harmed and dares to file a complaint (to try to seek help), as the wrongdoer. Any complaint about racism (and/or any other oppressive harm) must be immediately directed to a specific pathway where only racialized people and actual experts in anti-racism and anti-oppression deal with the complaint. The people tasked with managing racism complaints must have lived expertise on having to navigate the world with racism on an ongoing basis.

Every complaint must have a “power and privilege” and “power differential analysis” at the outset. As Archbishop Desmond Tutu has said, the system cannot be neutral in the face of oppressive harm complaints. There is no neutral. The inordinate amount of effort in protecting the “innocence until proven guilty” and confidentiality of the (white) respondent of a racism complaint (who already is afforded the benefit of the doubt over the racialized complainant, societally) means continued harm to the complainant through the inequity in the colonial processes and policies. Clear boundaries and safety measures must be immediately put in place for the complainant, and monitored. While I had called the Canadian Medical Protective Association (CMPA) for legal advice on how to navigate this complaint process, I was informed, to my incredulity, that they were not positioned to advise or support me, as the complainant, despite being a physician member who pays my medical-legal protection dues as required to practice. The respondent, however, would have been supported by the CMPA in this complaint. Talk about the system upholding systemic racism, power and privilege within the profession.

Existing in this society with its dehumanizing messages about racialized and Indigenous people creates internalized racism within racialized people that take decades to unpack, understand and actively resist. The fact that a racialized person would have concluded that making a complaint was required would have only resulted after much internal torture, self-gaslighting, and introspection. We would have already tried to obtain informal help because we know that the system is not set up to protect and support us. In my two cases where I needed to proceed with complaints, I had sought help repeatedly from people who had the power and jurisdiction within the institution to help me. I had had several “informal complaint” meetings with my Chair, and his predecessor, regarding “Jeff” over six years to no avail. This was despite having a thick file full of documentation of the various incidents over the years and many belligerent emails from him. One very high level white male superior advised me that I just had to put more effort into “making nice” with them (in a patriarchal, condescending tone akin to being patted on the head), but that I was just to carry on as I was “supported” by leadership in my work. Another white male superior said that I just had to get some white hair, some wrinkles, and not look like I was twelve to command respect. No one in a position of power to help me deal with these bullies was willing to step in because they didn’t want to upset the faculty members who had been at the institution for “such a long time”. In the situation regarding “Bill”, as detailed earlier, I was met with white fragility by everyone directly involved who could have used their white privilege to help me. Be it the silence, “staying out of it”, “remaining neutral”, “protecting oneself”, outright dismissal of the impact on me, “not seeing the racism”, or defending “Bill”, these were all forms of further covert racism inflicted on me by these colleagues. While two people within the physician group acknowledged in private that they could see that I had been attacked by “Bill”, when it came to actually putting their privilege on the line to speak up for me, they choose not to. They actively chose, instead, to harm me further by upholding the status quo at a critical time. It is near impossible to recover from such disappointment and betrayal from your colleagues.

Oppressive harm requires restorative justice to occur so that there is acknowledgement that violation of a person (and relationship) has occurred, not a violation of a law. Restorative justice focusses on healing of the individual harmed while requiring accountability from the respondent that also includes their own personal learning and growth. This process involves receiving an acknowledgement of harmful impact (regardless of intention), accountability for future incidents, and sending a clear message that lashing out at people in a gendered racist way is never acceptable, but especially in a workplace. The complaint process for racist and/or oppressive harm should be focused on the institution recognizing the complainant’s pain as a human being, not shielding those who cause harm and are already protected by the status quo of society and the institution. The person harmed should not be the person tasked with teaching everyone in the complaint process about racism and oppression, including racist gendered stereotypes, as I had to do ongoing over months to the several people who (mis)handled my complaint. This included, ironically, having to explain how covert racism exists to the third party white lawyers hired to investigate whether gendered racism had occurred. Leaders at every level in medicine must be competent to not only support those on their teams who have been harmed, but more importantly, to not further perpetuate harm through their defensive responses.

Complaints about racism and other intersectional oppressive harm must be acted upon as urgent, and concluded quickly within 8 to 12 weeks. At the conclusion of the complaint process, there must be a wrap-up meeting that not only discusses actions or outcomes, but determines what ongoing needs, changes and system feedback is required to help complainants who have experienced oppressive harm going forward. Institutions must understand that regardless of a complaint investigation being concluded, the complainant will be forever changed for having gone through the original harmful event, and the complaint process that dehumanizes them.

I resigned from my position last fall before the conclusion of the “investigation” for my complaint. That was how untenable my situation became over the eight months of the complaint process. The last straw was receiving yet another harmful email. After several requests that I not be present in regular administrative meetings with the respondent of my complaint, I was told that it had been decided that I was to meet with the whole physician group, or none of the group. This email was from a white woman physician colleague who had heard through my tears and anguish in the preceding months, the immense toll and impact that this whole ordeal was having on me and my family. If I had broken my leg and the elevator to an upper floor was out of service, would they have denied my reasonable accomodation if I had requested a meeting in the lobby so that I wouldn’t have to crawl up the stairs? If they did, this would be so disgustingly and overtly dehumanizing to make someone crawl up the stairs. My insistence that I not be in the presence of the person who was causing me ongoing harm, and the respondent of an ongoing complaint (itself a harmful process) was treated as unreasonable. I was essentially barred from being able to do my job while trying to advocate for my own safety. As Sara Ahmed writes, “You can be exhausted by not being accommodated; you can be exhausted by the work you have to do in order to [try to be] accomodated” (Ahmed 2021).

I was demoralized, exhausted and dehumanized. I had to end that pain for myself, and my family by resigning.

As you’re reading this, you might be thinking, what expertise do I have to demand such system changes? I have lived expertise as a racialized woman physician with disabilities working in Canadian healthcare institutions for 18 years, a medical educator who has supported countless racialized and otherwise oppressed learners who have experienced hardship due to oppression in their training, and a physician who has gone through and been failed by both the informal and formal complaint process at different stages of my medical career. Do not perpetuate epistemic injustice by thinking that my testimony, and my blood, sweat and tears in 18 years of experiences (23 years if you count my training years) do not carry any weight or expertise.

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In attempting to make sense of the injustices I have faced, I have read and researched this topic in the social psychology, sociology, psychology, medicine, social justice and anti-racism literature for years. As a qualitative medical researcher, I have attempted to make meaning from these injustices to enact institutional change to improve things for the next generation in medicine.

Epistemic injustice props up systemic racism within the policies and procedures in Canadian healthcare institutions. Epistemic racism plays out every day in Canadian society, in the silencing, exclusionary and disbelieving responses to discussions of racism, be it in the national news, or within organizations and workplaces. The dominant narrative has been formed by white people in society over time and continues to this day. This means that the lived experiences of racialized people are not only undisclosed or unheard, they are not believed and/or dismissed if heard because they don’t fit the dominant narrative (ie: the dominant group doesn’t suffer racism so does not “see” or understand racial harm). These exemplify the two ways in which epistemic racism exists: testimonial injustice (the person not being believed due to racism, subconscious or not) and hermeneutical injustice (not understanding or believing the interpretations of lived experiences by racialized persons because it doesn’t fit the dominant narrative). Harm is perpetuated through the stories of only the dominant group who then make the rules and direct the narratives upon which racist and oppressive harm is adjudicated. This is why all the white physicians with whom I worked in the second complaint were so quick to confidently dismiss and punish me for daring to utter the word racism in relation to a colleague and their group, when they have zero understanding of racism. It is also why I was overtly denied any accommodation when asking for protection from the respondent in not being in his virtual or physical presence, despite my clear articulation of the threat he posed to me. As a result, I was forced to give up clinical shifts (and income) because I was so fearful that being in his (to me, threatening) presence on the wards would adversely distract me in caring for patients safely. It is also why when asking for help, that other leaders could dare to say, “Well, none of the other physicians (all of whom are white) have stood up and supported you, so who are we to believe that racism occurred.” I did not need an investigation to confirm what I knew to be gendered racism.

This is why white men (and women) are defended so quickly in media stories about oppressive harm. This is why many racialized people who aspire to the seductive power and privilege in society that centres whiteness will give white people the benefit of the doubt over racialized people, especially women and non-binary people, even when they themselves are racialized. This occurred in my first complaint experience. Lateral violence from racialized colleagues in many ways, is more violent than racism from white people or institutions. How do we move past asking the question of “does systemic and other forms of racism exist within our healthcare organization or institution” to “what can we do to minimize the harm to racialized people within our organization and the healthcare system? How can we support them better within the organization to strive towards achieving equity?”

Ultimately, the question I have for all healthcare leaders across Canada is “do our voices, perspectives, and our lived expertise in having a lifetime of navigating colonial society as racialized individuals not matter within healthcare? Why must we endure racist harm in the workplace in silence and isolation?”

Every workplace policy must consider restorative justice principles to achieve what is earnestly being sought by complainants of oppressive harm; help to be seen and heard as a person with different needs, that impact matters more than intent, and that it is not punishment but accountability being sought. The complainant is simply trying to lessen their chances of such a harmful incident occurring again. We know it will occur again, especially if unchecked. This is our reality. We must not continue to exacerbate the harm of inequities in the workplace through complaint policies that only aggravate oppression by virtue of how they are written. More importantly, the process harms by being “disconnected from the problem the policy is intended to address” (Ahmed 2021). These policies themselves serve to only avoid the person harmed and the oppressive problems within the institution.

Since my most recent ordeal, some of my healing has been fostered through my work with the newly formed Anti-Racism Support Group in UBC’s Family Practice Residency Program. The decolonized approach to achieving restorative justice that our group strives for, led by an inspiring Indigenous Elder, gives me hope that colonial institutions can change and actively work towards safety and authentic support of racialized physicians in medicine. It is past due that all institutions concretely address the problems that complaints bring forth to those who have less institutional and societal power within medicine. It is past time that all institutions create explicit safety for racialized women and others who experience intersectional oppression, rather than continuing to burden those with less power and privilege, as the most affected, to fight to be seen and heard in these institutions. Only then, can physicians who are racialized women and other intersectional identities, and those who are coming after us, have any hope of surviving our careers in medicine.


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Power & Privilege in Canada

There’s been a lot of public discourse on racism, power & privilege, white supremacy and how it shows up in every day life in Canada for specific populations in Canada. That this is not seen or experienced by many people in society creates great distress and tension when major events that affect only certain populations that are marginalized by oppression occur. There are exclamations about being shocked when such events occur, and statements that these are only extreme events that don’t reflect the “true” nature of Canada. Sadly though, this is the true nature of Canada. We as a society have just invested heavily in denying this truth.

This is my attempt to conceptualize visually all the thoughts that have been tumbling in my mind over the last few months as I react to ongoing national and global events, while trying to process and learn more about white supremacy, settler colonialism, orientalism, racism, colonialism throughout the world, ableism, sexism and the displacement of people across the world. This work is necessary for all Canadians in our committment as a nation towards Truth and Reconciliation for First Nations, Inuit and the Metis Nation. It is also critical that we work past our false security that Canada is a free and open society, because for many Canadians all over the country, many people are in fact not free to live their authentic lives openly and unapologetically because it threatens long-held thoughts and “norms” based on a Euro-ethnocentric patriarchal and colonial construct.

I hope you find this tool (available for download at the end of this post) helpful in deepening your understanding, critical thinking and discussions about how we can create more inclusive, equitable and just spaces in society for each and everyone of us, regardless of our different intersecting privileges in a truly respectful, open and safe (for all) manner in Canada.

I sincerely thank my friends and colleagues who reviewed this tool for me and gave critical thought and feedback about the evolving language while challenging and pushing my thinking about these concepts. I am extremely grateful to Aimee Bouka MD, Alexandra Dobie MSW, Doug Myhre MD, Doreen Rabi MD, Jillian Ratti MD, Pamela Roach PhD, and Farha Shariff PhD for your invaluable contributions from your different perspectives and sharing of your expertise to what this graphic tool became with your edits and suggestions.

Please feel free to download this tool and share it for use in your discussions with people in your own circles. If you have any constructive feedback or comments, please share them either through the Contact form on this site, or below. Please note that inflammatory comments will not be addressed and will be removed.

Thank you.


This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

A tale of Asian triangulation and what that has to do with racism.

Let’s channel our own experiences of racist harm and ensure that we are working in solidarity for equity for all Black, Indigenous and People of Colour in Canada

Introductory Preface: My reflections and reactions to the tragic shooting targeting Asian women in Atlanta, Georgia on March 16, 2021


Like so many Asians in North America, I have been completely enraged and despaired at the tragic mass murder of 8 people in Atlanta, Georgia on Tuesday, March 16, 2021. As more details came out that 6 of the victims were Asian women who worked in three different Asian massage parlours, it became obvious to me that this was a racist and misogynist attack. The names of the victims hadn’t even been announced yet when the sheriff’s deputy, a white male, stated with such surety that the alleged gunman, a 21 year- old white male, had not been racially motivated because he allegedly told officers this, and that it was the result of being “fed up” and having a “bad day”. In one sentence, this police officer erased the humanity of these victims, and erased the collective experiences of racism that Asians and Asian women in particular have experienced since the mid-1800’s.

Say their names:

Soon Chung Park, 74; Hyun Jung Kim (Grant), 51; Soon Cha Kim, 69; Young Ae Yue, 63; Xiao Jie Tan, 49; Dao You Feng, 44; Delaina Ashley Yaun, 33; Paul Andre Michels, 54

How this tragedy was framed by law enforcement and many media reports touched off a social media firestorm where Asian women, anti-racism advocates and other racialized communities came out forcefully denouncing these dehumanizing remarks. Witnessing this as an Asian woman was empowering. Asian women all over North America and the world were explicitly shirking the age-old lessons we have been taught– to be diminutive, quiet, docile and stay silent—and speaking up loud and clear that we are no longer going to accept this erasure.

At the same time, media outlets were reporting on the gunman and his history in a sympathetic manner, rather than that of the victims. Was some of the dismissiveness of the victims due to the women possibly being linked to sex work in massage parlours? These victims were all human beings and did NOT deserve to be gunned down at their place of work. There has been very little coverage about the actual tragedy itself. Was white privilege at play here? There was coverage of what this police officer had said without any conversation that he won’t see the racism as a white man in society, and works within an American institution that is built on white supremacy, the political and socio-economic system that bestows advantages to white people as compared to other racial groups . This sheriff’s deputy identified and sympathized with the white male gunman and not those who were brutally killed, and there was no push back by the reporters at the press conference.

There has been little critical analysis on how this is a hate crime and of the layers of intersectional oppression of racism, sexism, classism, exploitation, and precarious immigration status that this tragedy exemplified:

How this was not a conversation about femicide or racism, but both and much more. The historical stereotype of East Asian women as exotic, demure, deferential and for sexual objectification and thus, to be valued less as human beings and be disposable when this white man has a bad day. That this stereotype harms all Asian women to this day because we are expected to act in a non-threatening and subservient manner in any workplace. The historical context of oppression, human trafficking and exploitation that results in many working-class Asian women to lead lives of indentured servitude in massage parlours and other marginalized businesses to pay off debts amidst their precarious immigration statuses in North America.

Would the coverage have been different if the victims were white and middle class? Would the coverage have been different if the gunman had not been white?

My guess is yes, it would have been different on all counts.

Beyond the media coverage, there has also been harmful discourse on social media that Asians in North America do not suffer from racism. Just because there does not exist a universal anti-Asian hate symbol doesn’t mean anti-Asian racism doesn’t exist. Look at the statistics during the COVID-19 pandemic regarding an increase in attacks on Asians in Canada. However, anti-Asian racism is not new to us. It has always existed. What this is bringing out is the many covert ways that racism exists and harms to this day in society. The extreme (often violent) events and extreme hate symbols are only the tip of the iceberg. Just like all racialized communities and the people within each community are unique, so too are our experiences with racism. This requires a nuanced exploration into the complexities of the racism that exists in Canada for all Black, Indigenous and People of Colour (BIPOC), without playing “Oppression Olympics“.

What people “see” as racism is only the tip of the iceberg.
Racism exists in many forms every day.
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I had written the following Op-Ed last week in an attempt to tease out some of these nuances as they exist in my medical profession as a call for solidarity in our fight for equity for all groups that identify as BIPOC. I didn’t feel that I could publish it at this time without an introductory preface that acknowledged the tragedy that occurred two days ago in Atlanta, Georgia and my personal reaction to the entire situation. I could have gone back into the OpEd and added references to this tragedy but I thought a separate introduction would be more explicit and honour the tragedy and my reactions to it.

I hope that this OpEd adds to the current conversation. Thank you.


A tale of Asian triangulation and what that has to do with racism.

Let’s channel our own experiences of racist harm and ensure that we are working in solidarity for equity for all Black, Indigenous and People of Colour in Canada

Dr Amy Tan

The racial justice reckoning that occurred after the death of George Floyd at the hands of the police in May, 2020 resulted in many institutions, including medical schools across Canada to make bold statements declaring their commitment to anti-racism. But what exactly has this led to? How exactly have organizations and institutions worked towards becoming truly anti-racist and anti-oppressive? Look at the comments from the publicly posted discussion by members on a draft “Equity and Diversity in Medicine policy” in 2019. These are my colleagues–physicians in Canada–and it was personally painful as an Asian physician to read many comments denying that racism exists and in fact showed many were invested in the colonial and white power structures in Canada and the healthcare system.

As a Chinese, heterosexual, settler of colour, second-generation Canadian, cis-gender female with more than one disability, I want to use my privilege and be part of the solution. I have had to think about race relations throughout every facet of my life since I was a child. I have mentored many BIPOC medical learners for over 15 years. I have also had many conversations with racialized learners through this year of racial reckoning, in which they have had to unpack navigating the pain of racist experiences while examining how they may have unwittingly upheld racist structures themselves. Many of these discussions have led to painful realizations that South/East Asians in medicine can be complicit in harming Black and Indigenous colleagues and learners. We have contributed to perpetuating racist and colonial toxicity that is layered upon the toxicity that comes from perfectionism, overwork, burnout, sexism, ableism, heterosexism, cis-genderism and mental health stigma for those in medicine.

How are we as Asians complicit? After all, we have been victims of racism too. East and South Asians have been historically discriminated against in Canada through immigration laws to limit Asian immigration, voting bans and political exclusion, and segregation. We all cannot forget that Japanese-Canadians were removed from their homes and forced to live in internment camps while providing hard labour and treated like criminals in their own country during World War II. Right now, East Asians are having a particularly difficult time being falsely blamed for the SARS-CoV-2 virus. There are daily reports of elderly Asian people being attacked on the streets completely unprovoked. Their only crime is that they look like they’re Chinese (some are actually Southeast Asian or Korean and that’s part of the same racism problem) and thus blamed for the pandemic and the restrictions because of it. The Vancouver Police Department has reported a 717% increase in anti-Asian hate crimes from 2019 to 2020 alone.

Yes, we Asians have felt the pain of being othered, even in medicine. We know what it feels like to be asked by patients and colleagues, “Where are you from? No, not Canada, but really where are you from?” or “Wow, your English is so good” or “I told you already that I wasn’t done with my dinner tray yet so don’t take it away- oh, I thought you were the dinner lady”. We know what it is like to be identified by another Asian name and to be given the message that we are all the same, a monolithic representation of a non-white group. We know how infuriating it is when you are 15 years into your career as an attending physician as an Asian woman, and the patient refers to the white male medical student working with you as the doctor, despite him having 21 years less experience in medicine than you. And these are only the microaggressions that we experience daily.

So, why is it that we are not channeling those demeaning feelings of not belonging to ensure that NO ONE feels like they are not safe to be authentic, to not belong, to be treated differently just because of their race?

Because it is difficult work to have to continually advocate for not only yourself, but others in medicine. The profession is challenging enough and there is often not enough hours or energy in a day to keep fighting against the tide of racism while doing the work of treating patients and reducing their suffering.

But here’s a hard truth: South/East Asians have been turning a blind eye to the harm inflicted on our Indigenous and Black colleagues because we have learned that our silence will be rewarded. Our communities have been enticed into the fantasy that we can enjoy some of the benefits that come with being “white-adjacent” in the socially constructed racial hierarchy that exists. We achieve this by distancing and distinguishing, and not denouncing colonialism and white supremacy at every turn.

Asians have been triangulated in relation to white people, and Indigenous and Black people in Canada. This triangulation means that we have benefited from white- adjacency while being limited in our belonging through the mechanisms of relative valorization (in which whites valorize Asians relative to Black or Indigenous people while dominating all groups) and civic ostracism (in which whites propagate that Asians are persistently foreign and thus must be limited in civic and political inclusion).

Racial Triangulation

The relative valorization has resulted in what is known in popular culture as the “model minority” concept that has put Asians on a conditional pedestal for our work ethic and apparent upward mobility in society. But this is a harmful myth, because describing Asians with one brush as a monolith (there are different experiences and many disparities even within the Asian diasporas in Canada) and then weaponizing us against Indigenous and Black people in Canada (by using South and East Asian upward mobility as misleading examples that systemic racism can’t occur) only serves to affirm the white superiority that exists in Canada.

Our parents and ancestors that immigrated to Canada made themselves as “small” as possible so as to not garner any attention to themselves as a means of survival against racism and xenophobia in these complex racial and colonial structures. In the tangled web of white supremacy and settler-colonialism in Canada, we are simultaneously “Forever Foreign” while benefitting from the colonialism of Indigenous people.

We have benefited in medicine from our collusion; South Asians and East Asians are over-represented in our profession. That’s not to minimize the hard work that got us into and through our medical training, but it’s to recognize the systemic structures in place that have given us privilege and benefits not extended to our Black and Indigenous colleagues. We must not deny the generations of systemic oppression that continue for Black and Indigenous communities to this day. We must use our privilege to change the medical culture from within for the benefit of ALL of us in the profession and our patients. Everyone benefits in a more inclusive and equitable profession.

Let’s channel our own experiences of racist harm to ensure that we are not complicit.

We Asians (like any BIPOC) can be both victim and perpetrator of racism and systemic racism. We must not hide behind the illusion that because we are victims of racism that we cannot inflict racist harm on other BIPOC.  There was a recent illustrative example of this very concept in the Globe and Mail. We all aspire to be white in Canada because existing in society has taught us that is to be coveted. And in doing so, we ourselves are prone to racist thoughts, acts and complicity by not denouncing it at every turn. We must not be silent when we witness anti-Black and anti-Indigenous racism within our profession by our colleagues and towards patients. This cannot be tolerated.

We do not get a free pass on doing the work required to be anti-racist and create brave anti-oppressive spaces in all spheres. As People of Colour, we have even more responsibility in how we engage in racist or anti-racist actions in solidarity with all racialized and Indigenous people. Yes, this is another place that as POC we are held to a higher standard. But if we do not uphold anti-racist actions and values in support of all BIPOC, then we are setting the wrong example and perpetuating harm to ourselves and others in medicine.

Racial justice must continue to be at the forefront of all medical leaders and citizens, even during the pandemic. The pandemic has shone a bright light on why racial justice must remain the priority because COVID-19 has exacerbated existing inequities in society; its solutions are inextricably linked to the systemic racism that exists in Canada. If COVID-19 has taught us anything, it is that we are woefully late with dismantling inequities in society. We MUST knock down the inequities that persist within the medical profession and decolonize the healthcare system for the collective health of our profession and for the patients in society that we serve. The majority white population in medicine has its own work to do to move anti-racism and anti-oppression forward, but we must reflect and look at the hard truths about our Asian complicity in all of this and how this perpetuates harm to our own communities too. We must use our painful lived experiences of racism to advocate for safer spaces for Asians while fighting in solidarity for equity for Black and Indigenous people. It is time that we Asians be on the right side of history and all embrace being co-disruptors to dismantle these structures.


This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Public Health needs to build trust & understanding with their patients at this stage of the pandemic:

Ruminations of a concerned and weary hospice physician~

COVID-19 Chronicles~

Originally published Jan 19, 2021 on amytan.medium.com~

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I just finished seven days of providing care to a whole unit of hospice patients. This means taking care of their symptoms with medications, but moreover, it entails answering the questions my patients who are well enough to ask of me, and those of their family members. On one day alone, I ended up conducting five family meetings for five of my patients. The family meeting is the “procedure” of palliative care. This is a critical part of the care we provide as palliative care clinicians because these meetings can shape the journey for both patients and families for an incredibly personal and poignant time in their lives.

I think it’s safe to say that the same is being experienced by all Canadians at this time during the SARS-COV-2 pandemic. Every single person is experiencing an emotional rollercoaster that is very personal right now. For many, this may be the single most challenging and isolating time in their life at a time when social isolation is required to stave off the vicious spread of this virus. Regardless of where the pandemic experience stacks in an individual’s life journey in terms of hardship, it has been hard in one way or another for everyone of us. The anxiety, fear and frustration among us all is palpable now, ten months into this “new normal”. As a Canadian, I’m worried and wondering what can be done to help with this collective distress, because we won’t have enough vaccines to actually end this pandemic for months to come. We must likely wait until the summer or fall before we will once again be able to safely hug each other and share a meal with those we cherish.

I’m worried that we can’t wait that long. Something different must be done now to help address the public’s distress.

Communication during a Public Health crisis is challenging. Every person in a population is the patient. Every person is distressed in some way. But I humbly think that pressers with media asking questions isn’t helping with the public’s level of distress anymore. Increasingly, we feel that the answers given are “talking points” rather than earnest addressing of the issues at hand. One-way communication is not helping the distress or adherence to public health measures. We can look to the successes that Indigenous communities have had with transparent, effective communication with active community engagement regarding COVID-19 responses.

As a hospice and family physician, I think that a more patient and family-centred approach, rather than the current paternalistic or maternalistic Public Health approach is needed so that people can feel heard and understood at these uncertain and stressful times.

In those five family meetings I conducted last week on the hospice unit, I was hit with a myriad of emotions and distress from my patients and their loved ones: stress about the prognosis, anger about a diagnosis not being made sooner, despair that a loved one was dying and there was nothing anyone could do to change the prognosis, spouses anticipating life without their life partner of 5 or 6 decades, disbelief that their loved one’s condition could have changed for the worse so quickly, desolation about how the pandemic was negatively impacting all factors for their family facing the death of the matriarch of their family, antagonism with working through family discord, and grief about the current visitor restrictions for their dying loved one.

Anguish, distress, fear, anxiety, anger, antangonism, fear of the unknown, uncertainty for the future. Sound familiar?

As part of my Master’s thesis project in Palliative Medicine, I developed a framework for having difficult conversations with patients’ loved ones that emerged after interviewing family physicians who provided end-of-life care for their patients. This has been seared into my consciousness and I use this framework subconsciously now in my clinical practice.

In addressing the palpable distress of my patients’ loved ones in these family meetings, I work to listen and validate their concerns, their anguish and their distress while gently correcting any misinformation they may have about the patient’s illness or diagnosis. This is a dance with the intent to help the patient and loved ones process this impossibly difficult situation, and not to be “right” or to defend the medical system. I can’t change the fact that my patients are dying in hospice (terminal illness has brought them to hospice), but I can help to change the journey of living until death for both my patient and their loved ones. I also strive to help the loved ones with their grieving that has already started in advance of their loved one’s death. I share with them that the situation they’re facing is unfair, that we don’t have all the answers in medicine, and that I wish so much that things could be different for my patient and their loved ones. I also try to introduce “Plan B’s” or the less palatable options that we could work through and what could be gained by thinking about these unwanted but perhaps necessary plans. I help them to reframe hopes and goals that are realistically achievable in the context of a patient who is dying, such as lessening pain, lessening shortness of breath, lessening confusion, while discussing what the trade-offs would be for managing these symptoms for the patient.

I always say in these family meetings that whatever information I have I will share with them as it is not my information to hold on to. It is also not about how hard things are for the clinical team during these family meetings; it is always centred around how the patient and loved ones are feeling. I work with them to understand, acknowledge and hopefully accept terrible news that no one wants to ever hear. False reassurance is paternalistic or maternalistic and worse than not helpful, as it can create more anxiety and harm.

I believe firmly that patients and families deserve to know whatever they need to know to process these difficult realities and to make informed choices for the time that is left for the patient.

It gives them a bit of power back in an otherwise powerless situation.

There are aspects of this approach that may be applicable and beneficial to help with the public’s distress around the pandemic at present. Specific areas that I see as origins of great public distress at present are:

-the horrific crisis in our long-term care (LTC) homes with 80% of deaths in Canada being in LTC, and the concerns around staffing, PPE, vaccines, living wages and paid sick leave for personal support workers,

-school safety and the actual rate of transmission to students in schools and the arguments over the false dichotomy between schools being closed or not (let’s work on mitigating risks IN the classrooms with universal mandatory masking in classrooms, ventilation improvements, smaller class sizes!),

-the fight to use of rapid tests within provinces (other than Nova Scotia) sent by the federal government in long-term care homes and/or schools to stave off cases and deaths,

-vaccine roll-out schedules and the seemingly haphazard (and at times unethical) determination of who gets their vaccine first,

-how far gone we are with the Test-Trace-Isolate strategy given the collapse of contact tracing in many jurisdictions,

-vaccine hesitancy concerns,

-the very slow uptake and acknowledgement of the science showing that aerosols and ventilation are a significant part of the transmission of this virus,

-the lack of an equity and anti-racist lens for the public health measures that is essential to protect the vulnerable who are already disproportionally impacted by COVID-19 (such as curfews not condemning those without a home to die in the cold or not having paid sick leave that would all people to stay home with symptoms and not worry about paying their rent or groceries),

-the confusion around the actual goals of the present restrictions and the chances that these goals will be achieved,

-the lack of clear or consistent metrics for the public to be able to track for progress towards a collective goal, and

-the siloed provincial and territorial approaches causing confusion in this social media age, and the lack of unified approaches and responses.

Simply dismissing the concerns of parents about school safety and saying that there’s hysteria about this among parents and teachers, evading business owners’ questions regarding the rationale for hours restrictions, denying the need to improve ventilation to mitigate the risk of this virus travelling further than 2 metres due to aerosols, or referring people to websites with out of date information to answer the public’s questions about how to incorporate safety plans into business and retail spaces isn’t working.

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Opportunities for governmental or public health designates to be available to answer real and concrete answers to questions, while committing to following-up with feedback of the public’s experiences of implementing public health measures are needed. The raw data needs to be made available so that people who need to or want to delve further into the information can do so to answer the questions they may need to know to better cope during their personal pandemic journey crisis.

I ask every patient how much information they want and assure them that there is no question that is out of bounds. I also say that if I don’t have the information at hand, I will try to find any available information to help answer their question. Sadly, there are some answers that I won’t have because I can’t turn back time for my patients. But governments have the ability to collect and share different data (of course if there’s a matter of security that requires some data to be classified, that’s understandable, but don’t use this as an excuse to not show data) in response to the public’s questions during the pandemic. It should not be for the governments to determine how much information is too much or not enough for the public. Advocates and members of the public from many different perspectives and disciplines should be encouraged to ask questions and better yet, be invited to have open dialogue with public health and government officials to consider the breadth of expertise available in solving the complex problems of the pandemic. Questions must be answered earnestly by public health and government officials to address the public’s concerns with a goal for full transparency*. Rather than being dismissed and unwelcome to have opinions about a health crisis that we’re ALL involved in, the public and advocates can help to amplify the correct information and answers from these dialogue opportunities. Dodging questions or hiding behind complicated or incomplete data does not address the public’s distress.

Perhaps adopting an approach similar to a family meeting for patients with palliative care needs would help to give the public a sense of some power in an otherwise powerless situation.

While communication in palliative care is not the same as the communication done by Public Relations or Crisis Management firms in politics, I think an approach that brings back the focus on the unique human experience during this crisis is needed now.

I’ve mapped out this approach and how it could apply to the Public Health crisis at hand by adopting and revising the framework that we developed in our research in 2011.

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More is needed during these hardest days with hospitals overwhelmed, increased cases, and new, more transmissible variants creating even more of a threat while there is fear and angst about the vaccines roll-out. Perhaps a new approach from government and public health officials could help with validating and acknowledging the public’s distress and the need for their questions to be earnestly answered. I would urge them to give it a try, for the sake of all of us.

*full transparency within reasonable security limits.

Christmas will be different this year, and it’ll be okay~

Christmas will be different this year, and it’ll be okay~

COVID-Chronicles 1: Originally published on Dec 12, 2020 on amytanmd.medium.com~

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Photo Credit: Amy Tan

It was our first Christmas together as husband and wife. We had just gotten married in September, and moved into our first home we purchased with our own money (and a little help from a big bank in the form of a nice mortgage). On December 1, 2002, we excitedly put up our new (fake) Christmas tree in front of our large picture window in the living room and decorated it with whatever decorations were on sale that year. We were just starting out and excited to do all the Christmas things that new homeowners and newlyweds did. This was well before Instagram and Pinterest but HGTV was my favourite channel, and we were brimming with excitement with starting our new holiday traditions. Our plans included having some semblance of turkey and the trimmings, stockings, gifts, gatherings with friends and extended family, a cocktail party at our new house, tickets to the Nutcracker ballet and more.

It became apparent the next day that Christmas would be different that year. Driving to work as a resident the next day, I swerved on black ice and my car careened across the 2-lane highway where I teetered over the edge of a small bridge. My blue Toyota Echo seesawed over the edge for what seemed to me like forever. Things literally went into slow motion for me. My car finally flipped over and under the bridge, crushing the bubble-like roof with me trapped inside and upside-down.

I have a smattering of memories from my weeks in hospital. Full c-spine precautions, a chest tube, being confused (yes, you can remember being confused!), surgery, the ICU, log rolls, late night strange lights and sounds, machines around me, dimpled ceiling tiles, nightmares, hospital roommates screaming in pain, CT scans and many Xrays. I remember learning how to balance on my feet again with a heavy plastic whole body clamshell cast immobilizing my broken spine from my neck to my tailbone and my left arm casted after surgery to repair the tendons and nerves, and the difficulty I had breathing because blood and fluid had collected in my right lung from where my crushed ribs had punctured my lung. My husband’s birthday came and went without any fanfare a week into my hospitalization. The days were getting closer to Christmas Day. Would I be spending our first Christmas as a married couple in the hospital?

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The clamshell brace/cast that I spent more than 6 months in while my broken back healed without risky surgery. Photo credit: Amy Tan

To be home for Christmas meant I had to prove to everyone I was safe to go home. To get out of bed, I needed to learn how to log roll myself onto my side as I couldn’t twist my unstable back, and my husband needed to learn how to put the clamshell cast on me. That was the first lesson. We practiced many times that day. The next day, it was turning on my left side after my husband got the clamshell on to pull myself up to a sitting position with my right hand because my left hand was out of commission from its injury. Over the next few days, I had to fight through dizziness, nausea, pain, fear, despair and defeat. There were so many sobs and tears. There were many times that I was convinced that there was no way I would be home for Christmas. But I kept on practicing getting up to a sitting position in my clamshell with the use of the bed grab bar. Slowly, I made progress — steps to the chair next to the bed, sitting down on the chair with a raised cushion seat, taking a few steps with a cane for balance. Then, it was learning how to walk to and sit on the (raised) toilet seat with the help of a grab bar.

On December 23, I proved to myself, my husband and my medical team that we were ready to go home. I was scared but determined. The next feat was having to be driven the thirty minutes home in a friend’s van while it was snowing without decompensating into a panic attack. Remember, the last time I had been in a car, I had almost died and it was snowing too that day. But I made it.

I was home for Christmas!

On Christmas Day, after a sleepless night due to pain, and my husband waking up every 2–3 hours by alarm to log roll me in bed (he slept on the floor next to me in our bed), we woke up and marveled that we had made it to our first Christmas morning in our first home after our ordeal. There weren’t many (any?) presents under the tree because we’d been a bit distracted. I didn’t last more than twenty minutes at a time before having to lie down and nap due to pain. I had an ice cream milkshake that day as that was the only thing that didn’t take a lot of effort to take in and tasted good at the time. I don’t remember what we had for Christmas dinner that day. There was no way we could have had any visitors that day. We were just trying to get through each day, hour-by-hour the first couple of weeks at home.

“Years later, all I truly remember is the feeling of Christmas that day.“

The awe that I had that I was alive, the gratitude of my husband taking such amazing care of me, the courage we had to face fear directly, and the amazement that we had convinced my medical team that I would be safe going home for Christmas, rather than the rehabilitation hospital. We had each other, very short phone calls with family and a few friends (as this was before texting and video chats), the movie, It’s a Wonderful Life, which took on a visceral level of poignancy that year, and our basic first Christmas tree in our own home. I also had deep gratitude for disability insurance and my husband’s understanding employer at the time. We didn’t get to host our first Christmas party as planned, there was no Nutcracker ballet that year, and we didn’t get to do any of the other fun holiday things around town that everyone else was revelling in. I would be lying if I didn’t say that there were moments that felt like I was missing out on the fun, but other pressing concerns forced me to accept the reality of the situation in the moment.

Christmas was different than we had planned that year, but it was okay. It was actually more than okay. Despite being isolated, in pain, and very uncertain of what our future would hold after my injuries, all that was important was right there with us that Christmas day.

“Let’s reframe how we view our holiday season this year. Instead of focusing on what we cannot do this month, let’s focus on what we can do and what these holidays are all about.”

This is all that any of us need this year — a simple Christmas and holiday season connecting virtually with our loved ones with the hope for brighter times in the future, and more celebrations to come down the road. For now due to where the world is with the pandemic, we need to dig deep and distill the holidays to the most essential elements. The holidays are about the feelings. Let’s embrace those feelings of loving each other and our neighbours by staying home to keep everyone safe this holiday season. Those who sadly must be in hospital over the holidays would give anything to be able to “just” be home. Let’s not forget that.

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The holidays are about the feelings. Photo credit: Amy Tan

For us all to be safe, we all need to do our part. If a million people bend the public health rules about COVID-19 in Canada, that’s at least a million more links to possible spread that we can’t afford right now, not to mention a lot of travel on winter Canadian roads that could land someone in an overstretched Canadian hospital over the holidays.

Eighteen years later, my husband and I don’t dwell on what could be described as a very difficult first Christmas. I don’t dwell on the fear and great physical pain I felt that day, or the thoughts of missing out. We look back at that Christmas with love and gratitude that we had the opportunity to have that first Christmas together, and the many more together that we’ve been so lucky to have since then, including now with our son.

And if that’s not the magic of Christmas, I don’t know what is.

2020 Chronicles: A year of anguish, despair, uncertainty & hope.~

COVID Chronicles 2 ~ Originally published on Dec 12, 2020 on amytanmd.medium.com~


Processing to create a pathway through the anguish, despair, uncertainty & hope of 2020.

I wrote a lot during this year to help with my own processing as a physician, as an activist, and as a human being.


Here are some of my stories that captured the many intense emotions and thoughts that I had at various points during this past year, given the COVID-19 pandemic and the racial reckoning that came finally after the horrific death of George Floyd and too many others in the USA and Canada at the hands of law enforcement.

I can only hope we don’t return to “normal” or the “status quo”. That all the inequitites in North American society that COVID-19 has shone a bright light to and exacerbated are not ignored, and we will actually move forward with meaningful change on racial justice and equity in so many realms in our society.

Some of my COVID Chronicles that I wrote and published online can be found here:

  1. We could have done this differently – and still can | The Sprawl
    I wonder what our response to COVID-19 would have been if SARS-CoV-2 hadn’t appeared in Wuhan, China, and was called…www.sprawlcalgary.com

2. In this pandemic, we are facing a tsunami of complicated grief
When I read this article about how one in five Canadians were found to be “cynical spreaders” of the novel coronavirus…rabble.ca

3. I also wrote an Op-Ed with my friend and colleague in response to the racial reckoning in the spring of 2020 and a call for allyship (or co-resisters):Ways to Be an Ally, from Two Lifetimes of Learning | The Tyee
The explosion of unrest in the U.S. in the wake of George Floyd’s death has led many Canadians to reflect on racism and…thetyee.ca

The haunting death that fuels my passion: a personal reflection~

Orginally published Sept 17, 2015 on amytan.medium.com~

“A young mother of 4 children in her 40’s, M*, was diagnosed with terminal breast cancer 4 weeks ago. She was referred, at the time of diagnosis, to a (new to her) family doctor who provides home visits for palliative care patients. At the first home visit, the physician speaks to the patient and her husband about the diagnosis, and how they are coping with this awful news. They have chosen not to tell their children (ranging in age from 8–17) that M’s disease is not curable. M and her husband are able to say aloud that she has a terminal prognosis, yet they are hopeful that she will rally and live much longer than the doctors have told her she would. M is extremely short of breath, requiring oxygen to help with her breathing. She has pain in her chest and ribs from the cancer that has spread into the lymph system in the lungs and bones. In the patient’s culture, talking about death is taboo, fearing that this topic will make death come faster. The doctor tries to sensitively broach this topic in order to prepare the patient and her husband for what is likely to come as death approaches with this disease: the shortness of breath, the pain and accompanying nausea and constipation from the medicines that treat the pain, and the fears about dying and about fighting to breathe, among others. The family doctor offers to talk to the children about what is going on and what to expect. She offers a referral to a social worker to help the patient’s children understand what is happening. These are refused despite the great pain M shows -both physically and emotionally- whenever her children are mentioned.

The doctor’s sixth home visit with M is on a Friday afternoon before a weekend. M is deteriorating quite quickly and again the doctor tries to broach the topic of telling the children what is happening so that they can try to prepare for the awful truth. She again is not successful. The doctor informs the Palliative Home Care service that she is available 24/7 for this patient.

The next night, M wakes up gasping for air and with incredible chest pain . There is fear and panic. 911 is called and M is taken to the Emergency Department of a large hospital by ambulance. A chest x-ray shows M’s lungs are full of cancerous fluid. The patient doesn’t want to be intubated or go to the intensive care unit, and so the Emergency team tries to keep her oxygen levels up with a machine that pushes positive pressure into the lungs. There are no beds available upstairs for her to be transferred to because it was a busy weekend of hospital admissions. M dies 15 minutes later, in a curtained off “bed” in the chaotic Emergency Department, with no privacy, no peace, and struggling to breathe right to the end. M’s husband watches this all and cannot understand nor believe what is happening. He doesn’t get to say goodbye to his wife of 20 years. He is completely shocked that his wife has just died in such a chaotic place. Their four children don’t have any idea that this is happening in the Emergency Department, and worse yet, that their mother has been moving through the terminal, dying phase of her life for at least the last four weeks.

The family doctor finds out the following Monday morning that her patient has passed away. “Why wasn’t she called?” was the first question she asks. Upon reviewing the above events in the Emergency Department report, the doctor cries for M, her family and their agony: the agony of both M and her family not being able to prepare for the end, and the agony of M’s loved ones being traumatized for years afterwards because of this death. This was NOT a good death. She had failed her patient.”

I am M’s doctor, and this happened years ago. Yet, M’s death still haunts me and I often wonder and worry about how her husband and children are doing. How did the children take the news that their mother died? Did the older teenaged children feel betrayed and cheated on the opportunity to say goodbye and prepare for their mother’s death?

I know the husband struggled because he dropped off a letter to my receptionist, asking me to fill out life insurance forms. In the letter, he described that his last memories of M were of her struggling to breathe, and asked to discuss all of this with me when he was ready. I left a message that of course he could discuss anything with me, when he felt that he was ready.

I never saw or talked to him again. The family had moved out of the province a few months later to be closer to family.

I wonder about M and her family every time I hear that a patient (who is expected to die from a terminal illness) has been rushed during a crisis into the acute care system and undergoes life-preserving or death-avoiding management at a critical time in the patient’s life —their death. These stories happen too often (still happening today!) and I wonder if there could be a better way.

I choose to believe that there has to be. But how do we get there?

In the years since M’s death, there has been great work done in many countries to help the public understand that Palliative Care focuses on relieving patients’ symptoms and stress of at anystage (including curative) of a life-limiting illness to improve the quality of life for both patients and their families (1). Palliative Care is not restricted to the end of life (2). Great progress has also been made with Advance Care Planning, which involves discussing and documenting patients’ health-care and end-of-life wishes (3,4).

However, there are still many issues that need to be addressed in the health care system to prevent more “bad” deaths like this. Why is the Emergency Room the only option for patients like M in the middle of the night? Well, it actually isn’t, but it appears to be the most common knee-jerk reaction to go to the Emergency Room when patients don’t know what else to do. This occurs even when there is Palliative Home Care in place for a patient, and a 24-hour phone number is given to the patients to ask questions or express a concern. In an ideal world, this phone call would lead to either reassurance over the phone, or a fairly immediate visit by the Palliative Care Nurse to help address the problem in person. The Palliative Care nurses that I work with are all wonderful, but there are usually only a handful of nurses available for an ENTIRE urban Canadian city, and its outlying areas, at any given time. The system is simply not able to have enough home care nurses available to go to every home to assess every call that is received at all hours of the day and night. In times of great stress and panic, however, many patients and their families need to be helped in person, not over the phone. In an ideal world, each of these patients at home with a terminal illness would have a Palliative Home Care nurse and a family physician who knows the patient and family, and are available 24/7 to be called upon, given that most Palliative Care is delivered by family medicine in Canada (5). But, this too is an unrealistic and unsustainable expectation.

An ideal world is not possible. But a better world and system could be made possible.

Society expects that babies will be born at all hours of the night. Kitchen table conversations around the world talk about birth stories and often start with “in the middle of the night….”. People everywhere read and discuss some variation of a “prepare for your baby’s birth” book out there and those who have not have been regaled with numerous stories and tips about what to expect and what to do, often unsolicited by friends, family and strangers alike. When a woman has a pregnancy-related concern in the middle of the night, she knows who to call, and where to go for care. In most larger communities, this place is the local Labour and Delivery ward, where healthcare teams are available in hospital overnight to help achieve the universal end goal of a healthy delivery for both baby and mom. My point is that most do plan extensively and prearrange for someone to be available to help them deliver his/her baby according to his/her wishes, otherwise known as “The Birth Plan”.

We as a society put so much discussion, planning and arranging into a person’s entrance into this world. Why does society not do the same for a person’s exit from this world? Both are guaranteed. We as a society so willingly share and hear from the experiences of others regarding birth, but not death. Why not?

Death is absolutely a scary thing to think and talk about. However, I’ve seen too many times that NOT talking about or planning for death can be even worse. We need doctors and healthcare teams to be better trained to talk about this in a culturally-sensitive and appropriate manner with patients (5), and we need society to be more open to discussing this as a way to make more deaths, however inevitable or unavoidable, better for the patient and loved ones.

Even with increased discussions and planning beforehand, there also needs to be more in place to support dying patients away from the hospital. Perhaps if the healthcare system was able to better support after-hours Palliative Care and End-of-Life care for a large capacity of patients outside of the Emergency Rooms, intensive care units and/or acute care hospitals, the public wouldn’t feel as though assisted dying is the only option when faced with a terminal diagnosis. My clinical experience has shown that most patients with a limited prognosis want to live longer, rather than die sooner, but would like to be as comfortable as possible in as home-like a place as possible, be it home, hospice or a long-term care facility. Supporting end-of-life care more effectively will even save health care dollars by keeping patients out of the acute care hospital beds, which would be an added benefit, rather than the primary intended goal.

Why isn’t there a designated urgent access facility for patients who are known to be dying to directly go to, if they are too overwhelmed at home when the time comes? The closest to this that I have seen has been in small rural hospitals where dying patients are moved out of the Emergency Department quickly to one of the few designated rooms in the small hospital reserved for dying patients. Why don’t we have, in larger hospitals, a parallel ward to the Labour and Delivery ward that would have the capacity to assess Palliative Care patients for a sudden unmanageable increase in their pain, or a sudden onset of confusion, nausea or shortness of breath if they can’t manage at home? They could be treated by a team focused on appropriate goal-oriented comfort care, including social workers, pastoral care, nurses, nurse practitioners, doctors, respiratory therapists, and be managed along with the regular family physician’s on-call team in accordance to the patient’s overall wishes. Patients and their families could be stabilized (medically and/or emotionally) over a few hours and return back home after collaborating with their family physician, or if more care is required, then a transfer to hospice or another more suitable in-patient ward could be made. These decisions would all be made with the ultimate goal to provide as peaceful an “expected” death as can be made possible for the patient, and for his/her loved ones.

To be clear: this is not assisted dying, this is effective Palliative Care providing comfort and ease of suffering at the natural end-of-life of a terminal patient.

In Canada, we are more than halfway into the longest federal election campaign ever, and only in the last couple of days, has health care even been mentioned (6). Palliative and End-of-life Care needs to be a priority, not just for politicians, but for all Canadians. As Canada’s population ages, and is expected to have more than 25% of the population aged 65 years and older by 2036 (7), the system will only be increasingly stressed with more patients facing prolonged chronic diseases (8,9), and/or the terminal phase of their lives and illness. There is also the unfortunate reality that terminal illness does not only occur in the elderly population, and support for all patients facing a life-limiting illnesses needs to be maximized, including that of younger adults and children. While I am in full support for a cohesive national senior’s health plan as advocated by the Canadian Medical Association and supported by the Canadian public (10,11), I believe that there also needs to be a related, but different discussion on a national Palliative Care and End-of-Life delivery plan that better serves the needs of not only the dying patients, but of the patient’s loved ones who are left picking up the pieces after the death of the patient. Their health and well-being after death is directly affected by their loved ones’ death and could have even longer term consequences on society and our health-care system with post-traumatic stress, or prolonged grief, depression or anxiety (12,13,14).

I do not have all the answers for all these questions that I ask, but I think we need to be asking more of these questions and trying to find some answers, in order to find a better way. I just hope that others will also ask themselves these questions, and want to help create a better way that will allow for more good deaths. This way, hopefully patient’s death stories like that of M’s above are more the rare exception rather than the all too common occurrence that is unfortunately currently happening.

*Details of the patient, M, (including name, demographics and disease state) were deliberately changed to protect patient anonymity and confidentiality.

References:

1. Center to Advance Palliative Care. What is Palliative Care. New York, NY Centre to Advance Palliative Care, 2012. Available from: https://getpalliativecare.org/whatis/ Accessed 2015 Sept 15

2. Canadian Hospice Palliative Care Association. FAQS: Definition of Palliative Care? Ottawa ON. Canadian Hospice Palliative Care Association, 2015. Available from [http://www.chpca.net/family-caregivers/faqs.aspx] Accessed 2015 Sept 15

3. Alberta Health Services. Advance Care Planning: Conversations Matter. Edmonton AB Alberta Health Services, 2015. Available from: [Conversationsmatter.ca] Accessed 2015 Sept 15

4. Canadian Hospice Palliative Care Association. Speak Up- Advance Care Planning in Canada. Ottawa, ON Canadian Hospice Palliative Care Association, 2015. Available from [www.advancecareplanning.ca] Accessed 2015 Sept 15

5. Shadd JD, Burge F, Stajduhar KI, Cohen SR, Kelley ML, Pesut B. Defining and measuring a palliative approach in primary care. Can Fam Physician 2013;59:1149–50. (Eng), 1156–7 (Fr).

6. Bailey I. Mulcair continues health-care push. The Globe and Mail. (2015, September 14).Available from: [http://www.theglobeandmail.com/news/politics/mulcair-promises-500-million-for-clinics-health-workers/article26356275/] Accessed 2015 Sept 15

7. Canadian Hospice Palliative Care Association. Fact sheet: hospice palliative care in Canada. Ottawa, ON: Canadian Hospice Palliative Care Association; 2014. Available from: www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf. Accessed 2015 Sept 15.

8. Canadian Hospice Palliative Care Association. Fact Sheet: Hospice Palliative Care in Canada. Ottawa ON Canadian Hospice Palliative Care Association, 2014. Available from [http://publications.gc.ca/collections/collection_2014/statcan/82-624-x/82-624-x2014001-2-eng.pdf] Accessed 2015 Sept 15.

9. Public Health Agency of Canada. Health-Adjusted Life Expectancy in Canada: 2012. Ottawa ON. Her Majesty the Queen in Right of Canada, 2012. Available from: [http://publications.gc.ca/collections/collection_2012/aspc-phac/HP35-32-2012-eng.pdf] Accessed 2015 Sept 15.

10. Picard A. Canadian Medical Association urges health-care strategy for seniors. The Globe and Mail. (2015, August 24). Available from:[http://www.theglobeandmail.com/news/national/canadian-medical-association-urges-health-care-strategy-for-seniors/article26087150/] Accessed 2015 Sept 15

11. Canadian Medical Association. CMA National Report Card 2015. Ottawa ON. Canadian Medical Association. Available from: [https://www.cma.ca/En/Lists/Medias/cma-national-report-card-2015.pdf?hootPostID=73c32759e704b8d68de4624a9491eafa] Accessed 2015 Sept 15.

12. Kirchhoff KT, et al: The vortex: families’ experiences with death in the intensive care unit. Am J Crit Care 2002, 11(3):200–209.

13. Carr D: A “good death” for whom? Quality of spouse’s death and psychological distress among older widowed persons. J Health Soc Behav 2003, 44(2):215–232.

14. Wright AA, et al: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008, 300(14):1665–1673.