Racism in medicine is real, with negative consequences for patients, physicians, and the public as a whole. This point is not in dispute. I have been a victim of racism on multiple occasions. Sometimes an interaction is so traumatic that I try to forget, to bury it and move on. The feeling that you're a second-class citizen makes it that much more difficult to carry out the day-to-day work of medicine.

Given the problem and prevalence of racism in medicine, it's time for a real overhaul one backed by concrete steps rather than symbolic ones. It doesn't matter if you change the name of a building or a street; what matters is the actionable steps taken to ensure that people are treated fairly.

That said, I wonder if we sometimes overreact to certain remarks because we assume, based on (traumatic) prior experiences, that they are coming from a bad place. I say this not to discount or diminish the very real racial discrimination suffered by myself and my colleagues every day. However, I've found that it's also possible to misinterpret certain questions or statements when we don't have more context.

I say this from my own personal experience. Let me share two examples.

This past December, a 74-year-old woman with colorectal cancer was waiting for me in the clinic. She has been on first-line chemotherapy of FOLFIRI for several months, but I was seeing her for the first time.

After I walk into the exam room, we chat a little to build rapport. Naturally, the discussion is about Canadian winter and Christmas.

Suddenly, she asks a question that takes me by surprise: "Are you allowed to celebrate Christmas?"

I am startled because the conversation so far has been pleasant. I reply rather tersely, "Apparently, it's not yet illegal in Canada for everyone to celebrate Christmas."

She doesn't pursue it further. We talk about blood work, toxicities, scans, the usual. Thankfully, there was no bad news before Christmas.

As I am about to wrap up our encounter, she launches into the topic again, saying, "My daughter-in-law never celebrated Christmas. She was a Hindu from India."

I stop. I am still a bit offended that she assumed I was from India (I am not), and that even if I were, she assumed I'd be a Hindu by default (though I am).

But at this point I'm also intrigued. I ask, "Was? You said your daughter-in-law 'was.' What happened?"

With tears in her eyes, she says, "She passed away young. She was nice. But she didn't know anything about Christmas and never celebrated one. I thought that was because of her religion."

I thought about this encounter for several hours after. I'd been offended by her suppositions and generalizations, but once home, I recalled that as children in Nepal, we referred to every White person as American, and every East Asian as Japanese. We were and still are surprised and amused when non-Hindus celebrate our festivals like Dashain and Holi alongside us in Nepal.

Now an argument can be made that this is merely lack of education, and that everyone, with the means, should educate themselves that such generalizations can be dangerous and hurtful. But in this case, I could see that the question had come from a place of genuine inquiry with the emotional overlay of her past experience. There was no intended slight against me.

On another day in December, I meet a 78-year-old man with metastatic prostate cancer, accompanied by his wife. The news isn't good. The scans show disease progression.

I am seeing them for the first time, and when I enter the exam room, I greet them. After some basic introduction, they ask me, "Where are you from?"

I immediately take offense at this classic line of racial stereotyping.

My response: "From Canada," hoping the two words would dead-end the conversation.

But they probe further.

"Now, where are you really from?" Again I answer "From Canada," wishing in this moment that masks and face shields could hide my identity.

And again: "No, where did you actually come from? Where were you born?"

By now I am irritated. I lie, saying, "In Canada. I was born in Canada." Not because I am not proud of my heritage (I am super-proud), but I have learned that people often ask these questions to racially profile, discriminate, and undermine.

At last, we turn to medical matters. I break the bad news, albeit not as well as I had hoped. To my surprise, they take it calmly.

The couple then asks about my holiday plans and mentions that one of their kids is coming back home and they are really excited.

And suddenly, they blurt out, "You know what, doc, we came here from the Czech Republic several years ago, and it has not been easy for us learning a new language and raising kids. This young son, he is now in medical school and will soon become a doctor. We are so proud of him. For immigrants like us, it really means a lot. This country has given us so much and we feel very grateful."

Wow. I realized that I had completely misunderstood them. They were asking about my roots because they saw their own son in me, as an immigrant. I had thought they must be Canadians because they looked White. The mistake wasn't theirs it was mine!

Finally, I told them that I was from Nepal. They were immediately interested, looking up Nepal in Google Maps. We embarked on a long discussion about different cultures. Toward the end of our conversation, they said they'd really like their son to grow up to be a doctor like me.

The biggest compliment came next: They asked if I could be their oncologist moving forward.

I'm relaying these encounters with patients not to generalize that all "Where are you from?" comments are innocuous. I have been on the receiving end of similar remarks from patients that were intended as microaggressions, or sometimes overt discrimination.

These interactions also made me recall that before I moved to North America, I always assumed that this kind of question came from a place of interest, and I took it as an opportunity to talk about my country and my culture. Only after moving to North America did I learn that these questions are not necessarily genuine or harmless.

However, after these two encounters with patients, I began to wonder whether I had transitioned from being unaware or less aware of the racial implications of certain questions to being overly sensitive. I also wondered whether I could channel this emotional energy into positive change.

And there's a lot of work to do. We need to address systemic racism in access to cancer care, cancer outcomes, healthcare workers' education, and career opportunities. We need to address deep-seated biases about people's appearances, ethnicity, and culture.

When racial minorities ask for equality, they are asking for equal access to education, treatment, career opportunities, and salary, as well as to justice, respect, and freedom. A world that doesn't address these issues but simply stops asking us where we come from is not the just world we are seeking.

Addressing these issues would go a long way toward creating a more level playing field, toward real equality. In such a world, being asked "Where do you come from?" would not feel so loaded with judgment about who I am. In that world, I might once again feel confident that this question comes from a genuine place of interest.

Bishal Gyawali, MD, PhD, is an associate professor in the Departments of Oncology and Public Health Sciences and a scientist in the Division of Cancer Care and Epidemiology at Queen's University in Kingston, Ontario, Canada, and is also affiliated faculty at the Program on Regulation, Therapeutics, and Law in the Department of Medicine at Brigham and Women's Hospital in Boston. His clinical and research interests revolve around cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. He tweets at@oncology_bg.

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Racism in Medicine: But Where Do You Really Come From? - Medscape