Intended for healthcare professionals

Opinion

When code-switching is a requisite on clinical rotations

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1898 (Published 29 July 2022) Cite this as: BMJ 2022;378:o1898
  1. Adjoa E Kusi-Appiah, final year medical student
  1. Michigan State University College of Human Medicine, East Lansing, Michigan, USA
  1. kusiapp1{at}msu.edu

Code-switching

I accompanied the resident on a ward round as she spoke smoothly and attentively to every patient. Another resident joined us who was of the same ethnicity as her. I watched as her posture relaxed and her voice, still smooth and attentive, revealed the more distinctive peaking of her Indian accent at the end of each word. She rolled in and out of these two mannerisms all day and I took note of each change. “This is what it looks like from the other side,” I thought to myself.

She was code-switching—an art, survival tactic, and routine that I knew too well. Code-switching is the act of changing or adjusting your language, accent, style of speech, or behaviour to assimilate to the environment and people present. It is often described as using the “customer service voice,” or “talking white” as my cousins would say. For me, both of these strategies are rooted in the historical exclusion of African Americans from certain spaces and professional roles, discrimination, and the macro and microaggressions that impose assimilation.

Surviving

I learnt to code-switch at an early age, and subsequent interactions reinforced it: “you are well spoken,” “you are not like other (black) girls.” Too young to decipher the troubling racial context of it all, I just saw that it “worked.” I was no longer looked over or blatantly disregarded as unintelligent. This positive reinforcement continued in medical school through comments from attending physicians and lecturers. On clinical rotations, operating in a space where no one looks like me, an environment I did not trust, I played it safe. I rolled in and out of a modified African American vernacular English to limit any chance of being mislabelled. I absorbed the idea that my more comfortable way of speaking was not compatible with professional environments, so I code-switched. Like many people from an ethnic minority group, I found that professionalism often seemed to be judged by its approximation to whiteness. Rarely are we given permission to display our own definition of professionalism that is intertwined in one’s culture, experiences, values, and self.

Even though our comfortable dialect is just as professional and clear, for some medical students from ethnic minority groups in predominantly white spaces, the unspoken requirement to code-switch is almost palpable. Inevitably, there is a toll that comes with code-switching, an exhaustion that is expressed in a deep sigh of release at the end of a long day. For me, it also came at the cost of diluting my one-of-a-kind voice, a voice that still manages to peek through during passionate conversations and when using my favourite catchphrases, like “I’m trippin.”

During one gruelling surgery rotation, when the energy I had left could only be used to stay awake, learn, and study hard, my capacity for code-switching was minuscule. My tone and cadence were my own, and my thoughts were vocalised. I talked with my hands and used my favourite soliloquies, and my patients appreciated my authenticity. I contributed to the team and performed my best academically, as usual. But one day on rounds when I was being questioned using the Socratic method, I was stopped at every other sentence by the attending on the ward, not for my medical knowledge but for the way I talked. “You need to sound smart… use words like ‘typically’…” ‘Typically?!’, I thought to myself, I would never use that. I wondered what “sound smart” meant. I was speaking clear English and using the correct medical terms. I laughed it off with the attending, but I walked away feeling defeated. Why am I expected to use words, a tone, and mannerisms that are completely inauthentic to me in a profession that already demands so much? This is a second job that I did not sign up for.

This reminded me of the United States former first lady Michelle Obama and her memoir Becoming where she shares the ways she was ridiculed and labelled. She details the inner struggle created by this tainted standard of professionalism and optics. She was determined to relay a different representation of professionalism. In her, I saw authenticity and I saw permission. The feeling would visit me again during my obstetrics rotation, where I was encouraged to turn the code-switch off.

Permission

I entered a room full of Black female clinicians (a novel experience for me), and I watched the group of professionals trade conversations back and forth. They were not code-switching. This was expected, as some people are less likely to code-switch when they are in a familiar environment. More people entered the room, I anticipated a shift in the group's tone and diction. but it remained the same, no code-switching. A sense of empowerment welled over me and I relaxed. Maybe it was their authority that made it easy to bypass code-switching? Maybe they were as tired as I was of ascribing to a distorted idea of professionalism? Maybe they rejected this survival technique a long time ago or never used it in the first place? All I knew was that I felt like I had permission and I used it.

Moments like this have been rare but the experience gave me a clearer picture of what it is like to be in a trusting environment and operate authentically. Still, my guard remains up as there is a risk of being stereotyped and overlooked. What if this system never creates space for the many voices, faces, and mannerisms that are possible in the fluidity of professionalism? I consider this question not just for me, but for our patients too, who value the richness of experience and individuality that lies in our authenticity.

I challenge everyone who plays a part in our medical system to check their interactions with colleagues and students: what are you feeding back to them and what biases does this reveal? We should all dig deep to examine the bar of professionalism we use to judge and compare medical students and doctors—think about the exemplar you have in your mind, what do they look like, sound like, and move like? We should all think about how we may be contributing to the construction of an environment that requires code-switching. Code-switching is just one survival tool that many minoritised students pack with them each day; are you making that bag heavier?

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned, not peer reviewed.

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