You are an ER doctor at a hospital who has just admitted a motorcyclist in his thirties who has sustained serious, but not life threatening, injuries due to drinking. You are scheduled to attend the patient who’s described as a “mean drunk.”
This is what Dr. Pauline Chen faced while treating a patient.
“I’m sure it freaked him out to have an Asian woman taking charge of his care,” a colleague told her after Chen described the patient’s swastika tattoo and aggressive reaction to her physical examination.
Dr. Chen’s experience was part of a recent New York Times story (July 30) concerning the ethics of doctor/patient relationships.
“What you need to do is turn this into a ‘teaching moment,’ ” Dr. Chen’s colleague told her. “Sit down with the patient and educate him about racism.”
This common scenario apparently plays out in hospitals around the country.
“Since Hippocrates,” Dr. Chen writes, “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?” Dr. Chen asks.
“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.
” ‘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,” Chen says. “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.’ ”
While many doctors face discrimination, Dr. Chen points out that non-physician providers as well as 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.’
“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.
” ‘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.’ ”
While the right and wrong here seem clear, in the context of the doctor-patient relationship, there are no easy answers.
From an ethical perspective, while doctors and health providers are susceptible to insulting behavior, even racially charged remarks, in the immediate aftermath of a medical emergency, a doctor’s first duty is to take care of the patient to the best of their ability. If a patient was both verbally and physically abusive, my first reaction might be to call in an anesthesiologist and put him or her to sleep as quickly as possible. However, those actions create their own rationalization: if it’s necessary, it’s ethical.
While the AMA’s code of professional conduct seems to cover a lot, the AMA is not standing in the room next to an attending physician under an attack of intolerance.
Sometimes, the best a healthcare provider can do is calmly and professionally explain to the patient what has happened and what they are doing to provide relief. If it becomes necessary to bring in a physician of another race, if one is available, to deal with the patient, that may be the best immediate course of action to take.
While more discussion is needed, the noble work of countless doctors, nurses, EMTs, fire, police and others should never be taken for granted or underestimated. However, in cases of discrimination, a doctor, not unlike a politician, must develop the hide of a rhino, and learn to ignore most of it.