Confronting the bigoted patient

Several years ago (and not at my present job), I had a new patient to admit.  The patient had been admitted as an urgent matter, and his family had not expected to be at the hospital that day.  (Alas, HIPAA prevents me from sharing some of the more piquant details of the story.)

The specifics of this child’s care required me to get on the phone to discuss the case with a specialist at the nearest academic medical center.  It was in the middle of our conversation that the patient’s father arrived on the floor.  I will never forget having to apologize to the physician on the other end of the line because I had lapsed into stupefied silence, and I hastened to explain why.

The man was wearing a T-shirt with a slogan emblazoned across it.  The slogan included both a crass reference to female anatomy and also a flagrantly homophobic slur.  (The Google informs me that apparently the words are from a “comedic” country song by one Mr. Rodney Carrington.)  And luck being a funny thing, the gentleman’s child had been assigned to me, the only gay pediatrician on staff at the hospital.

Charming.

After collecting myself, I finished talking with the doctor at the other medical center and went into the patient’s room to talk with the family about the child’s care.  All was going to be well, and I did my best to reassure everyone that despite the unexpected and urgent nature of the kid’s arrival at the hospital everything was going to be just fine.  As that conversation drew to a close, I asked the father if I might speak with him privately.  Drawing him aside, I explained that, while I was sure he’d had no idea he would have ended up at the hospital earlier that day, now that he was here it would be best if someone brought him a change of clothing.  Specifically, I told him that many different kinds of people worked at that hospital, and that the message on his shirt was likely to be deeply offensive to some of them.  Out of respect for the people who would be working hard to care for his child, removing it as soon as possible would be a good idea.

He seemed to take it in his stride.  However, he later complained to the nurse manager on the ward that I had infringed on his freedom of speech, or some such.  On learning of this and with an inward sigh, I called the hospital’s risk management officer to let him know about our interaction.  I am deeply gratified to report that the message I received was of unambiguous support, and that if the man’s complaint ever reached the administration he would be advised of the hospital’s policy of respect for all persons and non-discrimination.

I never heard a thing of it after that.

It never would have occurred to me to silently accept the message on the man’s shirt.  Thusly, I would never expect a medical provider to quietly tolerate any kind of message of discrimination or defamation from a patient, no matter if it was directed against their gender or ethnicity or sexuality or religion or anything else.  Naive fool that I am, I would have thought this attitude was broadly shared by the overwhelming, vast majority of my colleagues.  Not so much, it turns out?

From an article on dealing with racist patients in the New York Times:

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.

“Angry retorts” is doing a lot of lifting in that paragraph.  There are all manner of angry things Dr. Jain might have said that, yes, warranted an apology.  But if he merely called out the man’s racism, then expecting him to apologize is preposterous.

I have only ever encountered a patient (or rather, a patient’s family member) I considered overtly racist once.  It was in New York City, and I was approached by a father and asked to assign a resident to his child’s care who was both male and of the same ethnicity as their family.  As politely as I could, I explained that just as I could never possibly accommodate a request to keep doctors of the man’s ethnic group from caring for a specific patient, so too I could not assign a physician based on his preferences.  With that, I introduced him to the resident who was next up for an admission, Dr. Ling (a woman not of his ethnicity).

I did not (and do not now) consider his request a reflection of concern that his particular customs and norms would be not respected.  The hospital had many accommodations in place to best serve the needs of the man’s community, and I had no indication that the request was predicated on anything other than racial bias.  Just as it would never have even occurred to me to accept a patient’s homophobia, so too it would never have occurred to me to assign the admission in accordance with the man’s request.

So I was genuinely shocked to read this, further on in the same piece:

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.

The full text of the study is behind a subscription paywall and it doesn’t look like the journal is one I can access through my Children’s account.  But even looking at the abstract, I think the Times is grossly misrepresenting its findings.  The abstract’s conclusion reads:

Accommodating patient requests for providers of specific demographics within the emergency department may be related to provider characteristics. When patients ask for same gender providers, female providers are more likely to accommodate such a request than male providers. Female, non-white and Muslim patients may be more likely to have their requests honoured for matched providers. [emphasis mine, here and below]

To my reading, that implies the exact opposite of what the Times is saying.  Physicians are primarily deferring to minority patients, presumably in an effort to be culturally sensitive.  (For the record, the father I discuss above was white.)  I think there is a notable difference between catering to a request from a member of the majority culture not to have a member of a racial minority as a medical provider and the reverse.  Trying to find a doctor who speaks Mandarin, let’s say, is categorically different from deferring to a patient who doesn’t like Chinese people.  The Times is erasing that distinction when it cites this study as evidence in support of the article’s premise, misleadingly in my opinion.

Perhaps I am scrappier than most, but it strikes me as inconceivable to honor a request that minority medical providers not be assigned to bigoted patients.  And I question if that kind of insidious culture of accommodation is really as present in medicine as the Times would have us believe.  The piece concludes:

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.”

I dispute the “current stance” as stipulated in the article.  A few anecdotes about racist patients and naive colleagues does not a culture of tacit acceptance make.  The article also makes reference to a lawsuit that was fled when a black nurse was allegedly told that the hospital where she worked was acceding to a racist’s man’s demand that only white people touch his baby.  But from the linked article:

“In general, I don’t think honoring prejudicial preferences … is morally justifiable” for a health care organization, said Dr. Susan Goold, a University of Michigan professor of internal medicine and public health. “That said, you can’t cure bigotry. … There may be times when grudgingly acceding to a patient’s strongly held preferences is morally OK.”

[snip]

Another study she cited found that patient requests for care by a physician are most often accommodated when made by racial minority patients.

Look, I am white.  I have only worked in hospitals in major metropolitan area and/or the Northeast.  I therefore cannot speak with authority about the experiences of medical providers of a different race or in other areas of the country, and will defer to those who may dispute my assertions.  But I have a very hard to time believing that a stance of accommodation is the norm in medicine.  I just don’t think it is.  Perhaps there are occasions when acceding to a demand by a racist patient is the least worst possible option, but there’s a lot of daylight between rare accommodation and normative behavior.