Kimberly D Manning, MD

The collective struggle felt by healthcare workers simultaneously learning about and caring for patients impacted by SARS-CoV2 infections throughout 2020 was physically and emotionally exhausting. The majority of us had never experienced a global pandemic. Beyond our work in the professional arena of ambulatory practices and hospitals, we also felt the soul-crushing impact of the pandemic in every other aspect of our lives. Preexisting health disparities were amplified by COVID-19. Some of the most affected communities also bore the weight of an additional tsunami of ongoing racial injustice.¹ And as healthcare workers, we did our best to process and navigate it all while trying to avoid burnout—as well as being infected with COVID-19 ourselves. When the news of the highly effective vaccines against SARS-CoV2 receiving emergency use authorization broke late in 2020, it felt like a light at the end of a very dark tunnel.

In the weeks preceding wide availability of the vaccines, it became apparent that significant numbers of people lacked confidence in the vaccines. Given the disproportionate impact of COVID-19 on racial minorities, much of the discussion centered around “vaccine hesitancy” in these communities. Reasons such as historical mistrust, belief in conspiracy theories, and misinformation emerged as the leading explanations.² Campaigns and educational programs targeting Black Americans were quickly developed to counter this widely distributed narrative.

Vaccine uptake also became politicized, which created additional challenges. As schools and businesses reopened, the voices of those opposing pandemic mitigation mandates such as masking and vaccination were highlighted by media outlets. And though a large movement of individuals who had opted against vaccines existed well before the pandemic, with few exceptions, that number had never been great enough to impact public health to this extent.³ This primarily nonminority group of unvaccinated individuals also morphed into another monolithic identity: the “anti-vaxxer.”

The lion’s share of discussions around vaccine uptake centered on these two groups: the “vaccine hesitant” minority and the “anti-vaxxer.” The perspectives and frustration around these two stereotypical unvaccinated groups were underscored in journals and the lay press. But those working in communities and in direct care came into contact with countless COVID-19-positive patients who were unvaccinated and fell into neither of these categories. There was a large swath of vulnerable people who still had unanswered questions and mistrust in the medical system standing in their way. Awareness of health disparities among racial minorities is something that was discussed among providers, but it was something experienced and felt by patients daily in regard to so much more than just COVID-19.

With broader access to vaccines through retail, community-based, and clinical facilities, more patients who desired vaccination had the opportunity. After an initial rise in vaccine uptake, the numbers plateaued. But what remained was the repetitive messaging and sustained focus directed toward Black people and their “vaccine hesitancy.”

Grady Memorial Hospital, a public safety net hospital in Atlanta, serves a predominantly Black and uninsured patient population. We found that a “FAQ” approach with a narrow range of hypothetical ideas about unvaccinated minorities clashed with the reality of what we encountered in clinical environments and the community. While misinformation did appear to be prevalent, we appreciated that the context and level of conviction were heterogenous. We appreciated that each individual conversation could reveal something new to us about that unique patient and their personal concerns about vaccination. As time moved forward, it became clear that there was no playbook for any group, especially for historically disadvantaged communities. Importantly, it was recognized that attempts to anticipate what may be a person’s barrier to vaccination often worked to further erode trust. However, when we focused on creating a space for dialogue, we found we were able to move beyond information-sharing and instead were able to co-construct interpretations of information and co-create solutions that matched patients’ values and lived experiences.⁴ Through dialogue, we were better able to be transparent about our own experiences, which ultimately facilitated authentic conversations with patients.

In September 2021, we approached our hospital leadership with a patient-centered strategy aimed at providing our patients, staff, and visitors a psychologically safe place to discuss vaccine-related concerns without judgment. With their support, we set up a table in the busiest part of our hospital atrium between the information desk and vaccine-administration site. Beside it was a folding board sign with an image and these words:

“Still unsure about being vaccinated? Let’s talk about it.”

We aptly called the area the “No Judgment Zone.”

The No Judgment Zone is collaboratively staffed in 1- to 2-hour voluntary increments by physician faculty and resident physicians at Emory University School of Medicine and Morehouse School of Medicine. Our goal is to increase patient trust by honoring individual vaccine-related concerns without shame or ridicule. We also work to increase patient trust by being transparent around our own experiences with COVID-19; by sharing our own journeys, concerns, and challenges, we are better able to engage in meaningful dialogue. Also, recognizing the power of logistical barriers, in addition to answering questions, we offer physical assistance with check-in, forms, and escorts to our administration areas. The numbers of unique visits have varied from day to day, but the impact of each individual encounter cannot be overstated.

Here, we describe our approach to interactions at the No Judgment Zone. These are the instructions offered to our volunteers. Though we offer some explicit examples, each talking point is designed to open the door to a patient-centered individual dialogue. We believe that these strategies can be applied to clinical settings as well as any conversation surrounding vaccination with those who have not yet decided to be vaccinated.

No Labels

Try to think of all who are not yet vaccinated as “on a spectrum of deliberation” about their decision—not “hesitant” or “anti-vaxxer.”

Step 1: Gratitude

• “Thank you for stopping to talk to us today.”
• “I appreciate you taking the time.”
• “Before we start—I’m glad you’re here. Thanks.”

Step 2: Determine Where They Are

• Has the person you’re speaking with been vaccinated yet?
• If no, ask: “On a scale of 0 to 10—zero being “I will never get vaccinated under any circumstances” and 10 being ‘I will definitely get vaccinated’—what number would you give yourself?”
• If the person is a firm zero: “Is there anything I might be able to share with you or tell you about that might move you away from that perspective?”
• If the answer is NO: “It sounds like you’ve thought a lot about this and are no longer deliberating about whether you will be vaccinated. If you find yourself considering it, come back to talk with us, okay?” We are not here to debate or argue. We also need to avail ourselves to those who are open to changing their mind.
• If they say anything other than zero, move to an open-ended question about #WhatsYourWhy.

Step 3: #WhatsYourWhy

• “What would you say has been your main reason for not getting vaccinated yet?”
• “Tell me what has stood in the way of you getting vaccinated.”
• Remember: Assume nothing. It may have nothing to do with misinformation, fear, or perceived threat. It could be logistics or many other things. You will not know unless you ask.
• Providers should feel encouraged to also share their why as well and the reasons they encouraged their parents/kids/loved ones to get vaccinated. Making it personal can help establish connection and be more compelling.

Step 4: Listen Completely

• Give full eye contact. Slow all body movements. Use facilitative gestures to let the person know you are listening.
• Do not plan what you wish to say next.
• Limit reactions to misinformation. Shame and judgment can be subtle. Be mindful.
• Repeat the concern back if you are not sure or want to confirm that you’ve heard correctly.
• Ask questions for clarity if you aren’t sure.

Step 5: Affirm All Concerns and Find Common Ground

• “I can only imagine how scary it must be to take a shot that you believe could cause you to not be able to have babies.”
• “You aren’t alone. That’s a concern that many of my patients have had, too. May I share some information about that with you?”
• “When I first heard about the vaccine, I worried it was too new, too. Can I share what I learned?”

Step 6: Provide Factual Information

• Without excessive medical jargon, offer factual information aimed at each concern or question. Probe to be certain your patient understands through a teach-back or question.
• If you are unsure about the answer to their question, admit that you don’t know. You can also ask a colleague or the attending with you. Another option is to call someone or say “Let’s pull this up together.” Then share your answer.
• It is okay to acknowledge that the healthcare system has not and does not always do right by minority populations, especially Black people. Use that as a pivot to why these truths make vaccination that much more important
• Have FAQ information sheets available. Confirm that the patient is comfortable with the information sheet by asking.

Step 7: Offer to Help Them Get Vaccinated Today

• “Would you like me to help you get vaccinated today?”
• “What can I do to assist you with getting vaccinated? Is today a good day?”
• Escort those who agree to the registration area.
• Affirm those plans to get vaccinated or those who feel closer to getting vaccinated after speaking with you.

Step 8: Gratitude

• Close with gratitude and an affirmation.
• “I’m so glad you took the time to talk with us today. You didn’t have to stop.”
• “Feel free to come back to talk to us if you think of any more questions. I’m grateful that you stopped.”
• We are planting seeds. Do not feel pressure to get a person to say yes. Our secret sauce is kindness, respect, and empathy.
• We do not think of our unvaccinated community members as “hesitant.” We approach all as if they are on a spectrum of deliberation.

Step 9: Reflect

• Understand the importance of your service and the potential impact each encounter has.
• Recognize the unique lived experiences of individual patients and how this may impact their deliberation process. While there is urgency and we may feel frustrated, the ultimate goal is to engender trust through respectful interactions.
• Pause for moments of quiet gratitude and self-check-ins.

Just as SARS-CoV2 spreads from one person to many, we recognize that information—factual and otherwise—has the potential to move quickly as well. It is important to realize that providing an opportunity for people to ask questions or receive clarification and confirmation in a safe space is critical. The No Judgement Zone, as the name indicates, offers this opportunity. The conversations that we have in this space are valuable to those who are still considering the vaccine as an option for themselves. The trust required for such conversations is less about the transmission of information and more about the social act of engaging in bidirectional dialogue. The foundation upon which trust is built is consistent trustworthy actions. One such action is respectful communication without shame or ridicule. Another is our willingness to be transparent about our own concerns, experiences, and journeys. Assumptions based upon single-story narratives of the unvaccinated—particularly those from historically marginalized groups—fracture an already fragile confidence in medical authorities.

While we understand that mitigating the ongoing spread of the virus and getting more people vaccinated will call for more than just individual conversations, we believe that respecting the unique perspectives of community members is an equally critical piece to moving forward. Throughout a healthcare worker’s typical day, we work to create personal moments of connection with patients among the immense bustle of other work that has to be done. Initiatives like this one have a focused intentionality behind creating space for patients to feel heard that is not only helpful for vaccine uptake and addressing mistrust, but can also be restorative for providers as well.

The collective struggle felt by healthcare workers simultaneously learning about and caring for patients impacted by SARS-CoV2 infections throughout 2020 was physically and emotionally exhausting. The majority of us had never experienced a global pandemic. Beyond our work in the professional arena of ambulatory practices and hospitals, we also felt the soul-crushing impact of the pandemic in every other aspect of our lives. Preexisting health disparities were amplified by COVID-19. Some of the most affected communities also bore the weight of an additional tsunami of ongoing racial injustice.¹ And as healthcare workers, we did our best to process and navigate it all while trying to avoid burnout—as well as being infected with COVID-19 ourselves. When the news of the highly effective vaccines against SARS-CoV2 receiving emergency use authorization broke late in 2020, it felt like a light at the end of a very dark tunnel.

In the weeks preceding wide availability of the vaccines, it became apparent that significant numbers of people lacked confidence in the vaccines. Given the disproportionate impact of COVID-19 on racial minorities, much of the discussion centered around “vaccine hesitancy” in these communities. Reasons such as historical mistrust, belief in conspiracy theories, and misinformation emerged as the leading explanations.² Campaigns and educational programs targeting Black Americans were quickly developed to counter this widely distributed narrative.

Vaccine uptake also became politicized, which created additional challenges. As schools and businesses reopened, the voices of those opposing pandemic mitigation mandates such as masking and vaccination were highlighted by media outlets. And though a large movement of individuals who had opted against vaccines existed well before the pandemic, with few exceptions, that number had never been great enough to impact public health to this extent.³ This primarily nonminority group of unvaccinated individuals also morphed into another monolithic identity: the “anti-vaxxer.”

The lion’s share of discussions around vaccine uptake centered on these two groups: the “vaccine hesitant” minority and the “anti-vaxxer.” The perspectives and frustration around these two stereotypical unvaccinated groups were underscored in journals and the lay press. But those working in communities and in direct care came into contact with countless COVID-19-positive patients who were unvaccinated and fell into neither of these categories. There was a large swath of vulnerable people who still had unanswered questions and mistrust in the medical system standing in their way. Awareness of health disparities among racial minorities is something that was discussed among providers, but it was something experienced and felt by patients daily in regard to so much more than just COVID-19.

With broader access to vaccines through retail, community-based, and clinical facilities, more patients who desired vaccination had the opportunity. After an initial rise in vaccine uptake, the numbers plateaued. But what remained was the repetitive messaging and sustained focus directed toward Black people and their “vaccine hesitancy.”

Grady Memorial Hospital, a public safety net hospital in Atlanta, serves a predominantly Black and uninsured patient population. We found that a “FAQ” approach with a narrow range of hypothetical ideas about unvaccinated minorities clashed with the reality of what we encountered in clinical environments and the community. While misinformation did appear to be prevalent, we appreciated that the context and level of conviction were heterogenous. We appreciated that each individual conversation could reveal something new to us about that unique patient and their personal concerns about vaccination. As time moved forward, it became clear that there was no playbook for any group, especially for historically disadvantaged communities. Importantly, it was recognized that attempts to anticipate what may be a person’s barrier to vaccination often worked to further erode trust. However, when we focused on creating a space for dialogue, we found we were able to move beyond information-sharing and instead were able to co-construct interpretations of information and co-create solutions that matched patients’ values and lived experiences.⁴ Through dialogue, we were better able to be transparent about our own experiences, which ultimately facilitated authentic conversations with patients.

In September 2021, we approached our hospital leadership with a patient-centered strategy aimed at providing our patients, staff, and visitors a psychologically safe place to discuss vaccine-related concerns without judgment. With their support, we set up a table in the busiest part of our hospital atrium between the information desk and vaccine-administration site. Beside it was a folding board sign with an image and these words:

“Still unsure about being vaccinated? Let’s talk about it.”

We aptly called the area the “No Judgment Zone.”

The No Judgment Zone is collaboratively staffed in 1- to 2-hour voluntary increments by physician faculty and resident physicians at Emory University School of Medicine and Morehouse School of Medicine. Our goal is to increase patient trust by honoring individual vaccine-related concerns without shame or ridicule. We also work to increase patient trust by being transparent around our own experiences with COVID-19; by sharing our own journeys, concerns, and challenges, we are better able to engage in meaningful dialogue. Also, recognizing the power of logistical barriers, in addition to answering questions, we offer physical assistance with check-in, forms, and escorts to our administration areas. The numbers of unique visits have varied from day to day, but the impact of each individual encounter cannot be overstated.

Here, we describe our approach to interactions at the No Judgment Zone. These are the instructions offered to our volunteers. Though we offer some explicit examples, each talking point is designed to open the door to a patient-centered individual dialogue. We believe that these strategies can be applied to clinical settings as well as any conversation surrounding vaccination with those who have not yet decided to be vaccinated.

No Labels

Try to think of all who are not yet vaccinated as “on a spectrum of deliberation” about their decision—not “hesitant” or “anti-vaxxer.”

Step 1: Gratitude

• “Thank you for stopping to talk to us today.”
• “I appreciate you taking the time.”
• “Before we start—I’m glad you’re here. Thanks.”

Step 2: Determine Where They Are

• Has the person you’re speaking with been vaccinated yet?
• If no, ask: “On a scale of 0 to 10—zero being “I will never get vaccinated under any circumstances” and 10 being ‘I will definitely get vaccinated’—what number would you give yourself?”
• If the person is a firm zero: “Is there anything I might be able to share with you or tell you about that might move you away from that perspective?”
• If the answer is NO: “It sounds like you’ve thought a lot about this and are no longer deliberating about whether you will be vaccinated. If you find yourself considering it, come back to talk with us, okay?” We are not here to debate or argue. We also need to avail ourselves to those who are open to changing their mind.
• If they say anything other than zero, move to an open-ended question about #WhatsYourWhy.

Step 3: #WhatsYourWhy

• “What would you say has been your main reason for not getting vaccinated yet?”
• “Tell me what has stood in the way of you getting vaccinated.”
• Remember: Assume nothing. It may have nothing to do with misinformation, fear, or perceived threat. It could be logistics or many other things. You will not know unless you ask.
• Providers should feel encouraged to also share their why as well and the reasons they encouraged their parents/kids/loved ones to get vaccinated. Making it personal can help establish connection and be more compelling.

Step 4: Listen Completely

• Give full eye contact. Slow all body movements. Use facilitative gestures to let the person know you are listening.
• Do not plan what you wish to say next.
• Limit reactions to misinformation. Shame and judgment can be subtle. Be mindful.
• Repeat the concern back if you are not sure or want to confirm that you’ve heard correctly.
• Ask questions for clarity if you aren’t sure.

Step 5: Affirm All Concerns and Find Common Ground

• “I can only imagine how scary it must be to take a shot that you believe could cause you to not be able to have babies.”
• “You aren’t alone. That’s a concern that many of my patients have had, too. May I share some information about that with you?”
• “When I first heard about the vaccine, I worried it was too new, too. Can I share what I learned?”

Step 6: Provide Factual Information

• Without excessive medical jargon, offer factual information aimed at each concern or question. Probe to be certain your patient understands through a teach-back or question.
• If you are unsure about the answer to their question, admit that you don’t know. You can also ask a colleague or the attending with you. Another option is to call someone or say “Let’s pull this up together.” Then share your answer.
• It is okay to acknowledge that the healthcare system has not and does not always do right by minority populations, especially Black people. Use that as a pivot to why these truths make vaccination that much more important
• Have FAQ information sheets available. Confirm that the patient is comfortable with the information sheet by asking.

Step 7: Offer to Help Them Get Vaccinated Today

• “Would you like me to help you get vaccinated today?”
• “What can I do to assist you with getting vaccinated? Is today a good day?”
• Escort those who agree to the registration area.
• Affirm those plans to get vaccinated or those who feel closer to getting vaccinated after speaking with you.

Step 8: Gratitude

• Close with gratitude and an affirmation.
• “I’m so glad you took the time to talk with us today. You didn’t have to stop.”
• “Feel free to come back to talk to us if you think of any more questions. I’m grateful that you stopped.”
• We are planting seeds. Do not feel pressure to get a person to say yes. Our secret sauce is kindness, respect, and empathy.
• We do not think of our unvaccinated community members as “hesitant.” We approach all as if they are on a spectrum of deliberation.

Step 9: Reflect

• Understand the importance of your service and the potential impact each encounter has.
• Recognize the unique lived experiences of individual patients and how this may impact their deliberation process. While there is urgency and we may feel frustrated, the ultimate goal is to engender trust through respectful interactions.
• Pause for moments of quiet gratitude and self-check-ins.

Just as SARS-CoV2 spreads from one person to many, we recognize that information—factual and otherwise—has the potential to move quickly as well. It is important to realize that providing an opportunity for people to ask questions or receive clarification and confirmation in a safe space is critical. The No Judgement Zone, as the name indicates, offers this opportunity. The conversations that we have in this space are valuable to those who are still considering the vaccine as an option for themselves. The trust required for such conversations is less about the transmission of information and more about the social act of engaging in bidirectional dialogue. The foundation upon which trust is built is consistent trustworthy actions. One such action is respectful communication without shame or ridicule. Another is our willingness to be transparent about our own concerns, experiences, and journeys. Assumptions based upon single-story narratives of the unvaccinated—particularly those from historically marginalized groups—fracture an already fragile confidence in medical authorities.

While we understand that mitigating the ongoing spread of the virus and getting more people vaccinated will call for more than just individual conversations, we believe that respecting the unique perspectives of community members is an equally critical piece to moving forward. Throughout a healthcare worker’s typical day, we work to create personal moments of connection with patients among the immense bustle of other work that has to be done. Initiatives like this one have a focused intentionality behind creating space for patients to feel heard that is not only helpful for vaccine uptake and addressing mistrust, but can also be restorative for providers as well.

The collective struggle felt by healthcare workers simultaneously learning about and caring for patients impacted by SARS-CoV2 infections throughout 2020 was physically and emotionally exhausting. The majority of us had never experienced a global pandemic. Beyond our work in the professional arena of ambulatory practices and hospitals, we also felt the soul-crushing impact of the pandemic in every other aspect of our lives. Preexisting health disparities were amplified by COVID-19. Some of the most affected communities also bore the weight of an additional tsunami of ongoing racial injustice.¹ And as healthcare workers, we did our best to process and navigate it all while trying to avoid burnout—as well as being infected with COVID-19 ourselves. When the news of the highly effective vaccines against SARS-CoV2 receiving emergency use authorization broke late in 2020, it felt like a light at the end of a very dark tunnel.

In the weeks preceding wide availability of the vaccines, it became apparent that significant numbers of people lacked confidence in the vaccines. Given the disproportionate impact of COVID-19 on racial minorities, much of the discussion centered around “vaccine hesitancy” in these communities. Reasons such as historical mistrust, belief in conspiracy theories, and misinformation emerged as the leading explanations.² Campaigns and educational programs targeting Black Americans were quickly developed to counter this widely distributed narrative.

Vaccine uptake also became politicized, which created additional challenges. As schools and businesses reopened, the voices of those opposing pandemic mitigation mandates such as masking and vaccination were highlighted by media outlets. And though a large movement of individuals who had opted against vaccines existed well before the pandemic, with few exceptions, that number had never been great enough to impact public health to this extent.³ This primarily nonminority group of unvaccinated individuals also morphed into another monolithic identity: the “anti-vaxxer.”

The lion’s share of discussions around vaccine uptake centered on these two groups: the “vaccine hesitant” minority and the “anti-vaxxer.” The perspectives and frustration around these two stereotypical unvaccinated groups were underscored in journals and the lay press. But those working in communities and in direct care came into contact with countless COVID-19-positive patients who were unvaccinated and fell into neither of these categories. There was a large swath of vulnerable people who still had unanswered questions and mistrust in the medical system standing in their way. Awareness of health disparities among racial minorities is something that was discussed among providers, but it was something experienced and felt by patients daily in regard to so much more than just COVID-19.

With broader access to vaccines through retail, community-based, and clinical facilities, more patients who desired vaccination had the opportunity. After an initial rise in vaccine uptake, the numbers plateaued. But what remained was the repetitive messaging and sustained focus directed toward Black people and their “vaccine hesitancy.”

Grady Memorial Hospital, a public safety net hospital in Atlanta, serves a predominantly Black and uninsured patient population. We found that a “FAQ” approach with a narrow range of hypothetical ideas about unvaccinated minorities clashed with the reality of what we encountered in clinical environments and the community. While misinformation did appear to be prevalent, we appreciated that the context and level of conviction were heterogenous. We appreciated that each individual conversation could reveal something new to us about that unique patient and their personal concerns about vaccination. As time moved forward, it became clear that there was no playbook for any group, especially for historically disadvantaged communities. Importantly, it was recognized that attempts to anticipate what may be a person’s barrier to vaccination often worked to further erode trust. However, when we focused on creating a space for dialogue, we found we were able to move beyond information-sharing and instead were able to co-construct interpretations of information and co-create solutions that matched patients’ values and lived experiences.⁴ Through dialogue, we were better able to be transparent about our own experiences, which ultimately facilitated authentic conversations with patients.

In September 2021, we approached our hospital leadership with a patient-centered strategy aimed at providing our patients, staff, and visitors a psychologically safe place to discuss vaccine-related concerns without judgment. With their support, we set up a table in the busiest part of our hospital atrium between the information desk and vaccine-administration site. Beside it was a folding board sign with an image and these words:

“Still unsure about being vaccinated? Let’s talk about it.”

We aptly called the area the “No Judgment Zone.”

The No Judgment Zone is collaboratively staffed in 1- to 2-hour voluntary increments by physician faculty and resident physicians at Emory University School of Medicine and Morehouse School of Medicine. Our goal is to increase patient trust by honoring individual vaccine-related concerns without shame or ridicule. We also work to increase patient trust by being transparent around our own experiences with COVID-19; by sharing our own journeys, concerns, and challenges, we are better able to engage in meaningful dialogue. Also, recognizing the power of logistical barriers, in addition to answering questions, we offer physical assistance with check-in, forms, and escorts to our administration areas. The numbers of unique visits have varied from day to day, but the impact of each individual encounter cannot be overstated.

Here, we describe our approach to interactions at the No Judgment Zone. These are the instructions offered to our volunteers. Though we offer some explicit examples, each talking point is designed to open the door to a patient-centered individual dialogue. We believe that these strategies can be applied to clinical settings as well as any conversation surrounding vaccination with those who have not yet decided to be vaccinated.

No Labels

Try to think of all who are not yet vaccinated as “on a spectrum of deliberation” about their decision—not “hesitant” or “anti-vaxxer.”

Step 1: Gratitude

• “Thank you for stopping to talk to us today.”
• “I appreciate you taking the time.”
• “Before we start—I’m glad you’re here. Thanks.”

Step 2: Determine Where They Are

• Has the person you’re speaking with been vaccinated yet?
• If no, ask: “On a scale of 0 to 10—zero being “I will never get vaccinated under any circumstances” and 10 being ‘I will definitely get vaccinated’—what number would you give yourself?”
• If the person is a firm zero: “Is there anything I might be able to share with you or tell you about that might move you away from that perspective?”
• If the answer is NO: “It sounds like you’ve thought a lot about this and are no longer deliberating about whether you will be vaccinated. If you find yourself considering it, come back to talk with us, okay?” We are not here to debate or argue. We also need to avail ourselves to those who are open to changing their mind.
• If they say anything other than zero, move to an open-ended question about #WhatsYourWhy.

Step 3: #WhatsYourWhy

• “What would you say has been your main reason for not getting vaccinated yet?”
• “Tell me what has stood in the way of you getting vaccinated.”
• Remember: Assume nothing. It may have nothing to do with misinformation, fear, or perceived threat. It could be logistics or many other things. You will not know unless you ask.
• Providers should feel encouraged to also share their why as well and the reasons they encouraged their parents/kids/loved ones to get vaccinated. Making it personal can help establish connection and be more compelling.

Step 4: Listen Completely

• Give full eye contact. Slow all body movements. Use facilitative gestures to let the person know you are listening.
• Do not plan what you wish to say next.
• Limit reactions to misinformation. Shame and judgment can be subtle. Be mindful.
• Repeat the concern back if you are not sure or want to confirm that you’ve heard correctly.
• Ask questions for clarity if you aren’t sure.

Step 5: Affirm All Concerns and Find Common Ground

• “I can only imagine how scary it must be to take a shot that you believe could cause you to not be able to have babies.”
• “You aren’t alone. That’s a concern that many of my patients have had, too. May I share some information about that with you?”
• “When I first heard about the vaccine, I worried it was too new, too. Can I share what I learned?”

Step 6: Provide Factual Information

• Without excessive medical jargon, offer factual information aimed at each concern or question. Probe to be certain your patient understands through a teach-back or question.
• If you are unsure about the answer to their question, admit that you don’t know. You can also ask a colleague or the attending with you. Another option is to call someone or say “Let’s pull this up together.” Then share your answer.
• It is okay to acknowledge that the healthcare system has not and does not always do right by minority populations, especially Black people. Use that as a pivot to why these truths make vaccination that much more important
• Have FAQ information sheets available. Confirm that the patient is comfortable with the information sheet by asking.

Step 7: Offer to Help Them Get Vaccinated Today

• “Would you like me to help you get vaccinated today?”
• “What can I do to assist you with getting vaccinated? Is today a good day?”
• Escort those who agree to the registration area.
• Affirm those plans to get vaccinated or those who feel closer to getting vaccinated after speaking with you.

Step 8: Gratitude

• Close with gratitude and an affirmation.
• “I’m so glad you took the time to talk with us today. You didn’t have to stop.”
• “Feel free to come back to talk to us if you think of any more questions. I’m grateful that you stopped.”
• We are planting seeds. Do not feel pressure to get a person to say yes. Our secret sauce is kindness, respect, and empathy.
• We do not think of our unvaccinated community members as “hesitant.” We approach all as if they are on a spectrum of deliberation.

Step 9: Reflect

• Understand the importance of your service and the potential impact each encounter has.
• Recognize the unique lived experiences of individual patients and how this may impact their deliberation process. While there is urgency and we may feel frustrated, the ultimate goal is to engender trust through respectful interactions.
• Pause for moments of quiet gratitude and self-check-ins.

Just as SARS-CoV2 spreads from one person to many, we recognize that information—factual and otherwise—has the potential to move quickly as well. It is important to realize that providing an opportunity for people to ask questions or receive clarification and confirmation in a safe space is critical. The No Judgement Zone, as the name indicates, offers this opportunity. The conversations that we have in this space are valuable to those who are still considering the vaccine as an option for themselves. The trust required for such conversations is less about the transmission of information and more about the social act of engaging in bidirectional dialogue. The foundation upon which trust is built is consistent trustworthy actions. One such action is respectful communication without shame or ridicule. Another is our willingness to be transparent about our own concerns, experiences, and journeys. Assumptions based upon single-story narratives of the unvaccinated—particularly those from historically marginalized groups—fracture an already fragile confidence in medical authorities.

While we understand that mitigating the ongoing spread of the virus and getting more people vaccinated will call for more than just individual conversations, we believe that respecting the unique perspectives of community members is an equally critical piece to moving forward. Throughout a healthcare worker’s typical day, we work to create personal moments of connection with patients among the immense bustle of other work that has to be done. Initiatives like this one have a focused intentionality behind creating space for patients to feel heard that is not only helpful for vaccine uptake and addressing mistrust, but can also be restorative for providers as well.

We recently published an article in our Leadership & Professional Development series titled “Tribalism: The Good, the Bad, and the Future.” Despite pre- and post-acceptance manuscript review and discussion by a diverse and thoughtful team of editors, we did not appreciate how particular language in this article would be hurtful to some communities. We also promoted the article using the hashtag “tribalism” in a journal tweet. Shortly after we posted the tweet, several readers on social media reached out with constructive feedback on the prejudicial nature of this terminology. Within hours of receiving this feedback, our editorial team met to better understand our error, and we made the decision to immediately retract the manuscript. We also deleted the tweet and issued an apology referencing a screenshot of the original tweet.^1,2 We have republished the original article with appropriate language.³ Tweets promoting the new article will incorporate this new language.

From this experience, we learned that the words “tribe” and “tribalism” have no consistent meaning, are associated with negative historical and cultural assumptions, and can promote misleading stereotypes.⁴ The term “tribe” became popular as a colonial construct to describe forms of social organization considered ”uncivilized” or ”primitive.“⁵ In using the term “tribe” to describe members of medical communities, we ignored the complex and dynamic identities of Native American, African, and other Indigenous Peoples and the history of their oppression.

The intent of the original article was to highlight how being part of a distinct medical discipline, such as hospital medicine or emergency medicine, conferred benefits, such as shared identity and social support structure, and caution how this group identity could also lead to nonconstructive partisan behaviors that might not best serve our patients. We recognize that other words more accurately convey our intent and do not cause harm. We used “tribe” when we meant “group,” “discipline,” or “specialty.” We used “tribalism” when we meant “siloed” or “factional.”

This misstep underscores how, even with the best intentions and diverse teams, microaggressions can happen. We accept responsibility for this mistake, and we will continue to do the work of respecting and advocating for all members of our community. To minimize the likelihood of future errors, we are developing a systematic process to identify language within manuscripts accepted for publication that may be racist, sexist, ableist, homophobic, or otherwise harmful. As we embrace a growth mindset, we vow to remain transparent, responsive, and welcoming of feedback. We are grateful to our readers for helping us learn.

We recently published an article in our Leadership & Professional Development series titled “Tribalism: The Good, the Bad, and the Future.” Despite pre- and post-acceptance manuscript review and discussion by a diverse and thoughtful team of editors, we did not appreciate how particular language in this article would be hurtful to some communities. We also promoted the article using the hashtag “tribalism” in a journal tweet. Shortly after we posted the tweet, several readers on social media reached out with constructive feedback on the prejudicial nature of this terminology. Within hours of receiving this feedback, our editorial team met to better understand our error, and we made the decision to immediately retract the manuscript. We also deleted the tweet and issued an apology referencing a screenshot of the original tweet.^1,2 We have republished the original article with appropriate language.³ Tweets promoting the new article will incorporate this new language.

From this experience, we learned that the words “tribe” and “tribalism” have no consistent meaning, are associated with negative historical and cultural assumptions, and can promote misleading stereotypes.⁴ The term “tribe” became popular as a colonial construct to describe forms of social organization considered ”uncivilized” or ”primitive.“⁵ In using the term “tribe” to describe members of medical communities, we ignored the complex and dynamic identities of Native American, African, and other Indigenous Peoples and the history of their oppression.

The intent of the original article was to highlight how being part of a distinct medical discipline, such as hospital medicine or emergency medicine, conferred benefits, such as shared identity and social support structure, and caution how this group identity could also lead to nonconstructive partisan behaviors that might not best serve our patients. We recognize that other words more accurately convey our intent and do not cause harm. We used “tribe” when we meant “group,” “discipline,” or “specialty.” We used “tribalism” when we meant “siloed” or “factional.”

This misstep underscores how, even with the best intentions and diverse teams, microaggressions can happen. We accept responsibility for this mistake, and we will continue to do the work of respecting and advocating for all members of our community. To minimize the likelihood of future errors, we are developing a systematic process to identify language within manuscripts accepted for publication that may be racist, sexist, ableist, homophobic, or otherwise harmful. As we embrace a growth mindset, we vow to remain transparent, responsive, and welcoming of feedback. We are grateful to our readers for helping us learn.

We recently published an article in our Leadership & Professional Development series titled “Tribalism: The Good, the Bad, and the Future.” Despite pre- and post-acceptance manuscript review and discussion by a diverse and thoughtful team of editors, we did not appreciate how particular language in this article would be hurtful to some communities. We also promoted the article using the hashtag “tribalism” in a journal tweet. Shortly after we posted the tweet, several readers on social media reached out with constructive feedback on the prejudicial nature of this terminology. Within hours of receiving this feedback, our editorial team met to better understand our error, and we made the decision to immediately retract the manuscript. We also deleted the tweet and issued an apology referencing a screenshot of the original tweet.^1,2 We have republished the original article with appropriate language.³ Tweets promoting the new article will incorporate this new language.

From this experience, we learned that the words “tribe” and “tribalism” have no consistent meaning, are associated with negative historical and cultural assumptions, and can promote misleading stereotypes.⁴ The term “tribe” became popular as a colonial construct to describe forms of social organization considered ”uncivilized” or ”primitive.“⁵ In using the term “tribe” to describe members of medical communities, we ignored the complex and dynamic identities of Native American, African, and other Indigenous Peoples and the history of their oppression.

The intent of the original article was to highlight how being part of a distinct medical discipline, such as hospital medicine or emergency medicine, conferred benefits, such as shared identity and social support structure, and caution how this group identity could also lead to nonconstructive partisan behaviors that might not best serve our patients. We recognize that other words more accurately convey our intent and do not cause harm. We used “tribe” when we meant “group,” “discipline,” or “specialty.” We used “tribalism” when we meant “siloed” or “factional.”

This misstep underscores how, even with the best intentions and diverse teams, microaggressions can happen. We accept responsibility for this mistake, and we will continue to do the work of respecting and advocating for all members of our community. To minimize the likelihood of future errors, we are developing a systematic process to identify language within manuscripts accepted for publication that may be racist, sexist, ableist, homophobic, or otherwise harmful. As we embrace a growth mindset, we vow to remain transparent, responsive, and welcoming of feedback. We are grateful to our readers for helping us learn.

“Becoming is better than being.”

—Carol Dweck

The words spoken about her in the staff meeting were flattering. She’d just been acknowledged with a departmental teaching award for the second year in a row. With only 3 years under her belt since completing training, the former chief resident was living up to all they’d anticipated.

Eager students requested to be on her team and colleagues delighted in sharing patients with her. “Great, as always,” her peers and learners said in hallways and evaluations. This would come to define her identity.

Things were going well. She was succeeding. But she began to wonder if this reciprocating engine of accolades represented who she truly was. Was she really that good? Was she an imposter? In her performance meetings, the feedback never wavered: “Great, as always.”

The following year she would leave for a different job.

While specific plans for growth and improvement often get laid out for struggling colleagues and learners, far less effort is devoted to coaching high performers. Feedback that consists of nonspecific compliments may hinder potential, growth, and job satisfaction. We outline strategies for preventing this professional plateau in those you lead.

In Mindset: The New Psychology of Success, psychologist Carol Dweck describes how emphasis on qualities such as “being smart” or, in this example, “great,” underscores this “fixed mindset” that certain attributes are set in stone.¹ Conversely, she defines the “growth mindset” as a belief that potential can be cultivated through efforts. Even when there aren’t obvious issues with performance, the failure, fine-tuning, and feedback necessary for resilience and, ultimately, sustained growth require intention.

Emphasize Effort

Instead of lauding an individual for being “great, as always,” consider focusing on the effort it required to get there. For example, regarding the aforementioned junior colleague who’d just won awards, a typical compliment might be: “Wow, you’re on fire!” An option, to promote a growth mindset, might be: “You work very hard at bedside teaching and innovative curriculum development. I’m happy to see that our learners and department have recognized your commitment and effort.” This language also affirms others and makes achievements seem attainable to all.

Provide Active Coaching

Identifying specific opportunities for development can challenge individuals to expand their skills. Even those who are doing well have room to become even better. Coproduction of new milestones that push beyond current comfort zones can acknowledge current achievements while encouraging continued growth—and make things personal. For example, encouraging an individual to apply to a national faculty development program, such as the Society of Hospital Medicine’s Academic Hospitalist Academy, could help them expand their skills and social network.

Offer Meaningful Feedback

Prioritizing feedback is essential for growth and peak performance. This can be particularly powerful when the observer moves beyond basic expectations to incorporate personal goals. Concrete feedback measured against individual potential then takes the place of nondescript compliments. For example, you could say: “Your teaching on systolic ejection murmurs was on target for the students. Next time I want to challenge you to broaden your teaching script to include points appropriate for more seasoned learners.” This feedback leaves them with a set of tailored “marching orders” to guide practice and improvement.

No matter where a person stands on the spectrum of performance, growth in medicine relies on deliberate practice, active coaching, meaningful feedback, and graduated opportunities. Even the most proficient among us can stagnate without these things. If we aren’t careful, this reputational inertia could amplify imposter syndrome, prevent individuals from achieving their full potential, and threaten faculty retention. Intentional work toward a growth mindset allows everyone to grow—and be seen.

The authors have nothing to disclose.

“Becoming is better than being.”

—Carol Dweck

The words spoken about her in the staff meeting were flattering. She’d just been acknowledged with a departmental teaching award for the second year in a row. With only 3 years under her belt since completing training, the former chief resident was living up to all they’d anticipated.

Eager students requested to be on her team and colleagues delighted in sharing patients with her. “Great, as always,” her peers and learners said in hallways and evaluations. This would come to define her identity.

Things were going well. She was succeeding. But she began to wonder if this reciprocating engine of accolades represented who she truly was. Was she really that good? Was she an imposter? In her performance meetings, the feedback never wavered: “Great, as always.”

The following year she would leave for a different job.

While specific plans for growth and improvement often get laid out for struggling colleagues and learners, far less effort is devoted to coaching high performers. Feedback that consists of nonspecific compliments may hinder potential, growth, and job satisfaction. We outline strategies for preventing this professional plateau in those you lead.

In Mindset: The New Psychology of Success, psychologist Carol Dweck describes how emphasis on qualities such as “being smart” or, in this example, “great,” underscores this “fixed mindset” that certain attributes are set in stone.¹ Conversely, she defines the “growth mindset” as a belief that potential can be cultivated through efforts. Even when there aren’t obvious issues with performance, the failure, fine-tuning, and feedback necessary for resilience and, ultimately, sustained growth require intention.

Emphasize Effort

Instead of lauding an individual for being “great, as always,” consider focusing on the effort it required to get there. For example, regarding the aforementioned junior colleague who’d just won awards, a typical compliment might be: “Wow, you’re on fire!” An option, to promote a growth mindset, might be: “You work very hard at bedside teaching and innovative curriculum development. I’m happy to see that our learners and department have recognized your commitment and effort.” This language also affirms others and makes achievements seem attainable to all.

Provide Active Coaching

Identifying specific opportunities for development can challenge individuals to expand their skills. Even those who are doing well have room to become even better. Coproduction of new milestones that push beyond current comfort zones can acknowledge current achievements while encouraging continued growth—and make things personal. For example, encouraging an individual to apply to a national faculty development program, such as the Society of Hospital Medicine’s Academic Hospitalist Academy, could help them expand their skills and social network.

Offer Meaningful Feedback

Prioritizing feedback is essential for growth and peak performance. This can be particularly powerful when the observer moves beyond basic expectations to incorporate personal goals. Concrete feedback measured against individual potential then takes the place of nondescript compliments. For example, you could say: “Your teaching on systolic ejection murmurs was on target for the students. Next time I want to challenge you to broaden your teaching script to include points appropriate for more seasoned learners.” This feedback leaves them with a set of tailored “marching orders” to guide practice and improvement.

No matter where a person stands on the spectrum of performance, growth in medicine relies on deliberate practice, active coaching, meaningful feedback, and graduated opportunities. Even the most proficient among us can stagnate without these things. If we aren’t careful, this reputational inertia could amplify imposter syndrome, prevent individuals from achieving their full potential, and threaten faculty retention. Intentional work toward a growth mindset allows everyone to grow—and be seen.

The authors have nothing to disclose.

“Becoming is better than being.”

—Carol Dweck

The words spoken about her in the staff meeting were flattering. She’d just been acknowledged with a departmental teaching award for the second year in a row. With only 3 years under her belt since completing training, the former chief resident was living up to all they’d anticipated.

Eager students requested to be on her team and colleagues delighted in sharing patients with her. “Great, as always,” her peers and learners said in hallways and evaluations. This would come to define her identity.

Things were going well. She was succeeding. But she began to wonder if this reciprocating engine of accolades represented who she truly was. Was she really that good? Was she an imposter? In her performance meetings, the feedback never wavered: “Great, as always.”

The following year she would leave for a different job.

While specific plans for growth and improvement often get laid out for struggling colleagues and learners, far less effort is devoted to coaching high performers. Feedback that consists of nonspecific compliments may hinder potential, growth, and job satisfaction. We outline strategies for preventing this professional plateau in those you lead.

In Mindset: The New Psychology of Success, psychologist Carol Dweck describes how emphasis on qualities such as “being smart” or, in this example, “great,” underscores this “fixed mindset” that certain attributes are set in stone.¹ Conversely, she defines the “growth mindset” as a belief that potential can be cultivated through efforts. Even when there aren’t obvious issues with performance, the failure, fine-tuning, and feedback necessary for resilience and, ultimately, sustained growth require intention.

Emphasize Effort

Instead of lauding an individual for being “great, as always,” consider focusing on the effort it required to get there. For example, regarding the aforementioned junior colleague who’d just won awards, a typical compliment might be: “Wow, you’re on fire!” An option, to promote a growth mindset, might be: “You work very hard at bedside teaching and innovative curriculum development. I’m happy to see that our learners and department have recognized your commitment and effort.” This language also affirms others and makes achievements seem attainable to all.

Provide Active Coaching

Identifying specific opportunities for development can challenge individuals to expand their skills. Even those who are doing well have room to become even better. Coproduction of new milestones that push beyond current comfort zones can acknowledge current achievements while encouraging continued growth—and make things personal. For example, encouraging an individual to apply to a national faculty development program, such as the Society of Hospital Medicine’s Academic Hospitalist Academy, could help them expand their skills and social network.

Offer Meaningful Feedback

Prioritizing feedback is essential for growth and peak performance. This can be particularly powerful when the observer moves beyond basic expectations to incorporate personal goals. Concrete feedback measured against individual potential then takes the place of nondescript compliments. For example, you could say: “Your teaching on systolic ejection murmurs was on target for the students. Next time I want to challenge you to broaden your teaching script to include points appropriate for more seasoned learners.” This feedback leaves them with a set of tailored “marching orders” to guide practice and improvement.

No matter where a person stands on the spectrum of performance, growth in medicine relies on deliberate practice, active coaching, meaningful feedback, and graduated opportunities. Even the most proficient among us can stagnate without these things. If we aren’t careful, this reputational inertia could amplify imposter syndrome, prevent individuals from achieving their full potential, and threaten faculty retention. Intentional work toward a growth mindset allows everyone to grow—and be seen.

The authors have nothing to disclose.

“Hey there—just checking on you and letting you know I’m thinking of you.”

“I know words don’t suffice right now. You are in my thoughts.”

“If there’s any way that I can be of support or if there’s something you need, just let me know.”

The texts and emails have come in waves. Pinging into my already distracted headspace when, like them, I’m supposed to be focused on a Zoom or WebEx department meeting. These somber reminders underscore what I have known for years but struggled to describe with each new “justice for” hashtag accompanying the name of the latest unarmed Black person to die. This is grief.

With every headline in prior years, as Black Americans we have usually found solace in our collective fellowship of suffering. Social media timelines become flooded with our own amen choirs and outrage along with words of comfort and inspiration. We remind ourselves of the prior atrocities survived by our people. And like them, we vow to rally; clinging to one other and praying to make it to shore. Though intermittently joined by a smattering of allies, our suffering has mostly been a private, repetitive mourning.

The year 2020 ushered in a new decade along with the novel SARS-CoV2 (COVID-19) global pandemic. In addition to the thousands of lives that have been lost in the United States alone, COVID-19 brought with it a disruption of life in ways never seen by most generations. Schools and businesses were closed to mitigate spread. Mandatory shelter-in-place orders coupled with physical distancing recommendations limited human interactions and cancelled everything from hospital visitations to graduations, intergenerational family gatherings, conferences, and weddings.¹ As the data expanded, it quickly became apparent that minorities, particularly Black Americans, shouldered a disproportionate burden of COVID-19.² Known health disparities were amplified.

While caring for our patients as Black physicians in the time of coronavirus, silently we mourned again. The connection and trust once found through racial concordance was now masked figuratively and literally by personal protective equipment (PPE). We ignored the sting of intimations that the staggering numbers of African Americans hospitalized and dying from COVID-19 could be explained by lack of discipline or, worse, genetic differences by race. Years of disenfranchisement and missed economic opportunities forced large numbers of our patients and loved ones out on the front lines to do essential jobs—but without the celebratory cheers or fanfare enjoyed by others. Frantic phone calls from family and acquaintances interrupted our quiet drives home from emotionally grueling shifts in the hospital—each conversation serving as our personal evidence of COVID-19 and her ruthless ravage of the Black community. Add to this trying to serve as cultural bridges between the complexities of medical distrust and patient advocacy along with wrestling with our own vulnerability as potential COVID-19 patients, these have been overwhelming times to say the least.

Then came the acute decompensation of the chronic racism we’d always known in the form of three recent killings of more unarmed African Americans. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home after midnight on a “no knock” warrant.³ The story was buried in the news of COVID-19—but we knew. Later we’d learn that 26-year-old Ahmaud Arbery was shot and killed by armed neighbors while running through a Brunswick, Georgia, neighborhood. His death on February 23, 2020, initially yielded no criminal charges.⁴ Then, on May 25, 2020, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after a law enforcement official kneeled with his full body weight upon Floyd’s neck for over 8 minutes.⁵ The deaths of Arbery and Floyd were captured by cell phone cameras which, aided by social media, quickly reached the eyes of the entire world.

At first, it seemed plausible that this would be like it always has been. A Black mother would stand before a podium filled with multiple microphones crying out in anguish. She would be flanked by community leaders and attorneys demanding justice. Hashtags would be formed. Our people would stand up or kneel down in solidarity—holding fast to our historic resilience. Evanescent allies would appear with signs on lawns and held high over heads. A few weeks would pass by and things would go back to normal. Black people would be left with what always remains: heads bowed and praying at dinner tables petitioning a higher power for protection followed by reaffirmations of what, if anything, could be done to keep our own mamas away from that podium. We’ve learned to treat the grief of racism as endemic to us alone, knowing that it has been a pandemic all along.

The intersection of the crisis of the COVID-19 pandemic, complete with its social isolation and inordinate impact on minorities, and the acuity of the grief felt by the most recent events of abject racism have coalesced to form what feels like a pivotal point in the arc of justice. Like the bloated, disfigured face of lynched teenager Emmett Till lying lifeless in an open casket for the entire world to see in 1955,⁶ footage of these recent deaths typify a level of inhumanity that makes it too hard to turn away or carry on in indifference. The acute-on-chronic grief of racism felt by African Americans has risen into a tsunami, washing open the eyes of privileged persons belonging to all races, ethnicities, faiths, socioeconomic backgrounds, political views, and ages. The bulging neck veins, crackles, and thumping gallop rhythm of our hidden grief has declared itself: The rest of the world now knows that we can’t breathe.

Our moral outrage is pushing us to do something. Marches and demonstrations have occurred in nearly every major city. For those historically disenfranchised and let down by our societal contract, grief has, at times, met rage. Though we all feel an urgency, when we try to imagine ways to dismantle racism in the US it seems insurmountable. But as hospitalists and leaders, we will face black patients, colleagues, and neighbors navigating the pain of this exhausting collective trauma. While we won’t have all the answers immediately, we recognize the peculiar intersection between the COVID-19 crisis and the tipping point of grief felt by Black people with the recent deaths of Ahmaud Arbery, Breonna Taylor, and George Floyd, and it urges us to try.

Where can we start?

This is a time of deep sorrow for Black people. Recognizing it as such is an empathic place to begin. Everyone steers through grief differently, but a few things always hold true:

• Listen more than you talk—even if it’s uncomfortable. This isn’t a time to render opinions or draw suffering comparisons.
• Timely support is always appreciated. Leaders should feel the urgency to speak up early and often. Formal letters from leadership on behalf of organizations may feel like an echo chamber but they are worth the effort. Delays can be misunderstood as indifference and make the pain worse.
• The ministry of presence does not have to be physical. Those awkward text messages and emails create psychological safety in your organization and reduce loneliness. They also afford space to those who are still processing emotions and would prefer not to talk.
• Don’t place an expectation on the grieving to guide you through ways to help them heal. Though well-meaning, it can be overwhelming. This is particularly true in these current times.
• When in doubt, remember that support is a verb. Ultimately, sustained action or inaction will make your position clearer than any text message or email. Be sensitive to the unique intricacy of chronicity and missed opportunity when talking about racism.

Along with the pain we all feel from the impact of COVID-19, this is the time to recognize that your African American colleagues, patients, and friends have been navigating another tenacious and far more destructive pandemic at the same time. It is acute. It is chronic. It is acute-on-chronic. Perhaps 2020 will also be remembered for the opportunity it presented for the centuries old scourge of racism to no longer be our transparent cross to bear alone. Unlike COVID-19, this pandemic of racism is not “unprecedented.” We have been here before. It’s time we all grieve—and act—together.

“Hey there—just checking on you and letting you know I’m thinking of you.”

“I know words don’t suffice right now. You are in my thoughts.”

“If there’s any way that I can be of support or if there’s something you need, just let me know.”

The texts and emails have come in waves. Pinging into my already distracted headspace when, like them, I’m supposed to be focused on a Zoom or WebEx department meeting. These somber reminders underscore what I have known for years but struggled to describe with each new “justice for” hashtag accompanying the name of the latest unarmed Black person to die. This is grief.

With every headline in prior years, as Black Americans we have usually found solace in our collective fellowship of suffering. Social media timelines become flooded with our own amen choirs and outrage along with words of comfort and inspiration. We remind ourselves of the prior atrocities survived by our people. And like them, we vow to rally; clinging to one other and praying to make it to shore. Though intermittently joined by a smattering of allies, our suffering has mostly been a private, repetitive mourning.

The year 2020 ushered in a new decade along with the novel SARS-CoV2 (COVID-19) global pandemic. In addition to the thousands of lives that have been lost in the United States alone, COVID-19 brought with it a disruption of life in ways never seen by most generations. Schools and businesses were closed to mitigate spread. Mandatory shelter-in-place orders coupled with physical distancing recommendations limited human interactions and cancelled everything from hospital visitations to graduations, intergenerational family gatherings, conferences, and weddings.¹ As the data expanded, it quickly became apparent that minorities, particularly Black Americans, shouldered a disproportionate burden of COVID-19.² Known health disparities were amplified.

While caring for our patients as Black physicians in the time of coronavirus, silently we mourned again. The connection and trust once found through racial concordance was now masked figuratively and literally by personal protective equipment (PPE). We ignored the sting of intimations that the staggering numbers of African Americans hospitalized and dying from COVID-19 could be explained by lack of discipline or, worse, genetic differences by race. Years of disenfranchisement and missed economic opportunities forced large numbers of our patients and loved ones out on the front lines to do essential jobs—but without the celebratory cheers or fanfare enjoyed by others. Frantic phone calls from family and acquaintances interrupted our quiet drives home from emotionally grueling shifts in the hospital—each conversation serving as our personal evidence of COVID-19 and her ruthless ravage of the Black community. Add to this trying to serve as cultural bridges between the complexities of medical distrust and patient advocacy along with wrestling with our own vulnerability as potential COVID-19 patients, these have been overwhelming times to say the least.

Then came the acute decompensation of the chronic racism we’d always known in the form of three recent killings of more unarmed African Americans. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home after midnight on a “no knock” warrant.³ The story was buried in the news of COVID-19—but we knew. Later we’d learn that 26-year-old Ahmaud Arbery was shot and killed by armed neighbors while running through a Brunswick, Georgia, neighborhood. His death on February 23, 2020, initially yielded no criminal charges.⁴ Then, on May 25, 2020, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after a law enforcement official kneeled with his full body weight upon Floyd’s neck for over 8 minutes.⁵ The deaths of Arbery and Floyd were captured by cell phone cameras which, aided by social media, quickly reached the eyes of the entire world.

At first, it seemed plausible that this would be like it always has been. A Black mother would stand before a podium filled with multiple microphones crying out in anguish. She would be flanked by community leaders and attorneys demanding justice. Hashtags would be formed. Our people would stand up or kneel down in solidarity—holding fast to our historic resilience. Evanescent allies would appear with signs on lawns and held high over heads. A few weeks would pass by and things would go back to normal. Black people would be left with what always remains: heads bowed and praying at dinner tables petitioning a higher power for protection followed by reaffirmations of what, if anything, could be done to keep our own mamas away from that podium. We’ve learned to treat the grief of racism as endemic to us alone, knowing that it has been a pandemic all along.

The intersection of the crisis of the COVID-19 pandemic, complete with its social isolation and inordinate impact on minorities, and the acuity of the grief felt by the most recent events of abject racism have coalesced to form what feels like a pivotal point in the arc of justice. Like the bloated, disfigured face of lynched teenager Emmett Till lying lifeless in an open casket for the entire world to see in 1955,⁶ footage of these recent deaths typify a level of inhumanity that makes it too hard to turn away or carry on in indifference. The acute-on-chronic grief of racism felt by African Americans has risen into a tsunami, washing open the eyes of privileged persons belonging to all races, ethnicities, faiths, socioeconomic backgrounds, political views, and ages. The bulging neck veins, crackles, and thumping gallop rhythm of our hidden grief has declared itself: The rest of the world now knows that we can’t breathe.

Our moral outrage is pushing us to do something. Marches and demonstrations have occurred in nearly every major city. For those historically disenfranchised and let down by our societal contract, grief has, at times, met rage. Though we all feel an urgency, when we try to imagine ways to dismantle racism in the US it seems insurmountable. But as hospitalists and leaders, we will face black patients, colleagues, and neighbors navigating the pain of this exhausting collective trauma. While we won’t have all the answers immediately, we recognize the peculiar intersection between the COVID-19 crisis and the tipping point of grief felt by Black people with the recent deaths of Ahmaud Arbery, Breonna Taylor, and George Floyd, and it urges us to try.

Where can we start?

This is a time of deep sorrow for Black people. Recognizing it as such is an empathic place to begin. Everyone steers through grief differently, but a few things always hold true:

• Listen more than you talk—even if it’s uncomfortable. This isn’t a time to render opinions or draw suffering comparisons.
• Timely support is always appreciated. Leaders should feel the urgency to speak up early and often. Formal letters from leadership on behalf of organizations may feel like an echo chamber but they are worth the effort. Delays can be misunderstood as indifference and make the pain worse.
• The ministry of presence does not have to be physical. Those awkward text messages and emails create psychological safety in your organization and reduce loneliness. They also afford space to those who are still processing emotions and would prefer not to talk.
• Don’t place an expectation on the grieving to guide you through ways to help them heal. Though well-meaning, it can be overwhelming. This is particularly true in these current times.
• When in doubt, remember that support is a verb. Ultimately, sustained action or inaction will make your position clearer than any text message or email. Be sensitive to the unique intricacy of chronicity and missed opportunity when talking about racism.

Along with the pain we all feel from the impact of COVID-19, this is the time to recognize that your African American colleagues, patients, and friends have been navigating another tenacious and far more destructive pandemic at the same time. It is acute. It is chronic. It is acute-on-chronic. Perhaps 2020 will also be remembered for the opportunity it presented for the centuries old scourge of racism to no longer be our transparent cross to bear alone. Unlike COVID-19, this pandemic of racism is not “unprecedented.” We have been here before. It’s time we all grieve—and act—together.

“Hey there—just checking on you and letting you know I’m thinking of you.”

“I know words don’t suffice right now. You are in my thoughts.”

“If there’s any way that I can be of support or if there’s something you need, just let me know.”

The texts and emails have come in waves. Pinging into my already distracted headspace when, like them, I’m supposed to be focused on a Zoom or WebEx department meeting. These somber reminders underscore what I have known for years but struggled to describe with each new “justice for” hashtag accompanying the name of the latest unarmed Black person to die. This is grief.

With every headline in prior years, as Black Americans we have usually found solace in our collective fellowship of suffering. Social media timelines become flooded with our own amen choirs and outrage along with words of comfort and inspiration. We remind ourselves of the prior atrocities survived by our people. And like them, we vow to rally; clinging to one other and praying to make it to shore. Though intermittently joined by a smattering of allies, our suffering has mostly been a private, repetitive mourning.

The year 2020 ushered in a new decade along with the novel SARS-CoV2 (COVID-19) global pandemic. In addition to the thousands of lives that have been lost in the United States alone, COVID-19 brought with it a disruption of life in ways never seen by most generations. Schools and businesses were closed to mitigate spread. Mandatory shelter-in-place orders coupled with physical distancing recommendations limited human interactions and cancelled everything from hospital visitations to graduations, intergenerational family gatherings, conferences, and weddings.¹ As the data expanded, it quickly became apparent that minorities, particularly Black Americans, shouldered a disproportionate burden of COVID-19.² Known health disparities were amplified.

While caring for our patients as Black physicians in the time of coronavirus, silently we mourned again. The connection and trust once found through racial concordance was now masked figuratively and literally by personal protective equipment (PPE). We ignored the sting of intimations that the staggering numbers of African Americans hospitalized and dying from COVID-19 could be explained by lack of discipline or, worse, genetic differences by race. Years of disenfranchisement and missed economic opportunities forced large numbers of our patients and loved ones out on the front lines to do essential jobs—but without the celebratory cheers or fanfare enjoyed by others. Frantic phone calls from family and acquaintances interrupted our quiet drives home from emotionally grueling shifts in the hospital—each conversation serving as our personal evidence of COVID-19 and her ruthless ravage of the Black community. Add to this trying to serve as cultural bridges between the complexities of medical distrust and patient advocacy along with wrestling with our own vulnerability as potential COVID-19 patients, these have been overwhelming times to say the least.

Then came the acute decompensation of the chronic racism we’d always known in the form of three recent killings of more unarmed African Americans. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home after midnight on a “no knock” warrant.³ The story was buried in the news of COVID-19—but we knew. Later we’d learn that 26-year-old Ahmaud Arbery was shot and killed by armed neighbors while running through a Brunswick, Georgia, neighborhood. His death on February 23, 2020, initially yielded no criminal charges.⁴ Then, on May 25, 2020, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after a law enforcement official kneeled with his full body weight upon Floyd’s neck for over 8 minutes.⁵ The deaths of Arbery and Floyd were captured by cell phone cameras which, aided by social media, quickly reached the eyes of the entire world.

At first, it seemed plausible that this would be like it always has been. A Black mother would stand before a podium filled with multiple microphones crying out in anguish. She would be flanked by community leaders and attorneys demanding justice. Hashtags would be formed. Our people would stand up or kneel down in solidarity—holding fast to our historic resilience. Evanescent allies would appear with signs on lawns and held high over heads. A few weeks would pass by and things would go back to normal. Black people would be left with what always remains: heads bowed and praying at dinner tables petitioning a higher power for protection followed by reaffirmations of what, if anything, could be done to keep our own mamas away from that podium. We’ve learned to treat the grief of racism as endemic to us alone, knowing that it has been a pandemic all along.

The intersection of the crisis of the COVID-19 pandemic, complete with its social isolation and inordinate impact on minorities, and the acuity of the grief felt by the most recent events of abject racism have coalesced to form what feels like a pivotal point in the arc of justice. Like the bloated, disfigured face of lynched teenager Emmett Till lying lifeless in an open casket for the entire world to see in 1955,⁶ footage of these recent deaths typify a level of inhumanity that makes it too hard to turn away or carry on in indifference. The acute-on-chronic grief of racism felt by African Americans has risen into a tsunami, washing open the eyes of privileged persons belonging to all races, ethnicities, faiths, socioeconomic backgrounds, political views, and ages. The bulging neck veins, crackles, and thumping gallop rhythm of our hidden grief has declared itself: The rest of the world now knows that we can’t breathe.

Our moral outrage is pushing us to do something. Marches and demonstrations have occurred in nearly every major city. For those historically disenfranchised and let down by our societal contract, grief has, at times, met rage. Though we all feel an urgency, when we try to imagine ways to dismantle racism in the US it seems insurmountable. But as hospitalists and leaders, we will face black patients, colleagues, and neighbors navigating the pain of this exhausting collective trauma. While we won’t have all the answers immediately, we recognize the peculiar intersection between the COVID-19 crisis and the tipping point of grief felt by Black people with the recent deaths of Ahmaud Arbery, Breonna Taylor, and George Floyd, and it urges us to try.

Where can we start?

This is a time of deep sorrow for Black people. Recognizing it as such is an empathic place to begin. Everyone steers through grief differently, but a few things always hold true:

• Listen more than you talk—even if it’s uncomfortable. This isn’t a time to render opinions or draw suffering comparisons.
• Timely support is always appreciated. Leaders should feel the urgency to speak up early and often. Formal letters from leadership on behalf of organizations may feel like an echo chamber but they are worth the effort. Delays can be misunderstood as indifference and make the pain worse.
• The ministry of presence does not have to be physical. Those awkward text messages and emails create psychological safety in your organization and reduce loneliness. They also afford space to those who are still processing emotions and would prefer not to talk.
• Don’t place an expectation on the grieving to guide you through ways to help them heal. Though well-meaning, it can be overwhelming. This is particularly true in these current times.
• When in doubt, remember that support is a verb. Ultimately, sustained action or inaction will make your position clearer than any text message or email. Be sensitive to the unique intricacy of chronicity and missed opportunity when talking about racism.

Along with the pain we all feel from the impact of COVID-19, this is the time to recognize that your African American colleagues, patients, and friends have been navigating another tenacious and far more destructive pandemic at the same time. It is acute. It is chronic. It is acute-on-chronic. Perhaps 2020 will also be remembered for the opportunity it presented for the centuries old scourge of racism to no longer be our transparent cross to bear alone. Unlike COVID-19, this pandemic of racism is not “unprecedented.” We have been here before. It’s time we all grieve—and act—together.