When the Patient Is Racist

Kimani Paul-Emile in The New York Times Well Blog, July 25, 2013

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By PAULINE W. CHEN, M.D.

After too many drinks, the motorcycle enthusiast in his 30s had driven off the side of the road. As one of the doctors-in-training covering trauma that night, I was responsible for his initial physical exam; but it wasn’t going to be easy. He was enormous, his feet hung over the flimsy emergency room gurney and his neck bulged out of the stiff cervical collar. Moreover, he was what the older nurses called a “mean drunk,” so it was with more than a little apprehension that I began palpating and poking.

He glared at me, his eyes filled with loathing, and his thick muscles twitched under my every touch. I moved from his head down to his shoulders and chest, relieved not to have to look in those eyes. But when I pushed against his ribs, feeling for any instability that might signify broken ribs, he shouted and raised one of his massive arms as if to hit me. On his biceps, under the splattered blood, I could make out a brilliant indigo swastika.

I shuddered.

The patient had suffered only broken bones, so after my evaluation I was happy to leave him to the orthopedic surgeons. When I expressed my relief to a colleague, he smiled. “I’m sure it freaked him out to have an Asian woman taking charge of his care,” he said after I had described the patient’s menacing tattoo and threatening reaction to me.

But then my colleague paused. “What you need to do is turn this into a ‘teaching moment,’” he finally said without the slightest hint of irony. “Sit down with the patient and educate him about racism.”

I remembered this colleague’s naïve remark, and the burly patient with the swastika tattoo, when I read an essay by Dr. Sachin H. Jain in a recent issue of The Annals of Internal Medicine on the medical profession’s attitude toward patients who discriminate against doctors.

Since Hippocrates, physicians have embraced the ideal of caring for all patients, regardless of who they might be. While the father of medicine struggled to be open-minded when it came to caring for slaves, doctors more recently have wrestled with caring for patients’ of different races, gender and sexual orientation. In 2000, the American Medical Association codified its opinion on the issue, issuing in its code of ethics a mandate that doctors could not refuse to care for patients based on any “invidious” discriminatory criteria like race or ethnicity.

But what does the doctor do when the patient discriminates?

In his thought-provoking essay, Dr. Jain, an attending physician at the Boston V.A. Medical Center, describes an encounter with a hospitalized patient who is upset over a pharmacy regulation. Frustrated that he cannot obtain his usual type of insulin, the patient turns on Dr. Jain. “You people are so incompetent,” he says. “Why don’t you go back to India?”

The patient’s outburst calls up painful memories for Dr. Jain, who fires back angry retorts as he walks out of the patient’s room, only to regret later what he has done. He hands over the patient’s care to another doctor, but finds when he seeks out the advice and support of colleagues that they are quick to admonish him and even make light of the patient’s behavior. One doctor even urges Dr. Jain to go back to the patient’s room and apologize.

“What are our obligations,” Dr. Jain writes, “when we are the subject of their inhumanity, cruelty or intolerance?”

The essay illustrates the paradox that exists in medicine’s attitude toward race. Doctors are under strict ethical provisions not to refuse patients, and in medical school and during training, they learn to filter their own responses in order to help patients feel safe and secure.

But many extend these lessons in modulating one’s responses to situations where patients make demands and behave in ways that in any other public setting would be considered discriminatory or even racist. One study, for example, revealed that up to almost a third of doctors would, without question, concede to a patient’s demand for physicians of a certain race, ethnicity, gender or religion.

“It’s medicine’s ‘open secret,’” said Kimani Paul-Emile, an associate professor of law at Fordham University who has written extensively on the topic. “The medical profession knows this happens but doesn’t want to talk about it.”

The repercussions of this professional blind eye are most difficult not for doctors, but for nurses, aides and other staff. Unlike physicians who might experience such discrimination on occasion, nonphysician providers and hospital or nursing home workers are in a particularly vulnerable position because they are in constant contact with patients and have less control over policies regarding patient requests. One recent lawsuit involved a hospital that barred a black nurse from caring for or even touching a white patient’s baby, revealing the extent to which patient requests are accommodated. But there is a far larger problem with what sociologists and psychologists refer to as “micro-aggressions,” subtle but crippling insults, indignities and demeaning behavior.

“Nurses and ancillary staff are on the front lines of patient care,” Dr. Jain said. “They feel the effects of our willingness to accept a wide range of behaviors from patients every day.”

The answer, however, isn’t easy. Race and ethnicity appear to exert a tremendous influence on patients’ experience of being ill and their sense of satisfaction with care. Moreover, several recent studies indicate that a provider’s race, ethnicity, gender and even social class do make a difference. Patients tend to receive better care from providers who are most like them.

Still, the medical profession’s current stance is far from ideal. Ongoing initiatives in medical schools and training programs to increase diversity among the next generation of doctors will likely have an effect; but much more needs to be done to foster open and nuanced discussions of the profession’s attitude toward race and ethnicity and to assess the profession’s at times overly exuberant interpretations of “putting the patient first.”

“There’s something wrong,” Dr. Jain said, “when a person can go to work, be subject to intolerance or abuse and have it be ignored and accepted by colleagues as part of the job.”