MEdIC Series: The Case of the Discriminatory Patient 

2017-09-28T21:45:56+00:00

Welcome to season 5, episode 1 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case of a junior resident faced with discrimination while treating a patient who refuses to be seen by a “non-white” or “non-Canadian” physician.

MEdIC: The Case of the Discriminatory Patient

By Arden Azim, BScN, MD(Candidate)

It was a busy night in the emergency department (ED), and Dr. Young was working with a first year emergency resident, Natasha, and a first year surgical resident, Steven. Natasha was born in India but immigrated at the age of 2, and subsequently grew up and completed all of her schooling (including medical school) in Toronto, Canada. Dr. Young had worked with her before, and was already impressed with her clinical competency and bedside manner.

Several hours into the shift, Natasha checked in with Dr. Young to review several of her patients. After discussing their cases, Dr. Young scanned the board and found a suitable patient for Natasha to see next. “Why don’t you go see Mrs. Richardson? You mentioned you wanted more orthopedic exposure, and based on the triage note, she likely has a fracture from her fall this evening. You may even get to do a nerve block and reduce her wrist. Go see her and let me know what we’re dealing with!”

Mrs. Richardson, an older white woman, has been waiting for hours and was clearly uncomfortable, cradling her wrist. Natasha began the interview but Mrs. Richardson seemed frustrated and quickly became dismissive of Natasha’s questions and asked her to repeat herself several times. Natasha assumed her behaviour reflected the pain she was in so she reassured her patient that once she answered a few more questions she would have the nurses administer some pain medications. Mrs. Richardson, appearing very unimpressed, interrupted, “Sorry, but I just can’t understand what you’re saying. Not to be rude, but can I get another doctor? A Canadian doctor?”

Caught off guard, Natasha stumbled over her words, “Um… I am Canadian… I grew up in this city and completed by schooling here. I’m sorry you’re having trouble understanding me, what can I clarify for you?”

Mrs. Richardson sighed in frustration, shaking her head.

“No! I don’t want to talk to you anymore. I want a Canadian doctor – you know, a white one. One that clearly speaks English in a way I can understand. Surely there’s at least one here!” Natasha stood in silence for a few seconds, staring at Mrs. Richardson in complete shock. She then slowly turned to walk out of the room, mumbling that she will have her attending physician come see the patient.

Dr. Young was busy juggling several sick patient, but tried to sympathize, “I’ll try to talk to Mrs. Richardson later. In the meantime, Steven, you see her so Natasha doesn’t have to go in there again.”

Natasha was very obviously upset, so Dr. Young placed a hand on her shoulder and tried to reassure her, “You know how some older patients are. It’s a shame, but don’t take it personally.”

Steven was, of course, exactly everything that Mrs. Richardson was expecting in a doctor: Tall, handsome, male… and Caucasian. Within seconds, Natasha and Dr. Young could see that he had easily won her over. With him in the room, she seemed pleasant and agreeable. Later, Steven approached Natasha and reassured her that the patient did not make any other racist or discriminatory comments during the the remainder of the encounter. Her wrist was reduced and splinted and she was sent home.

Natasha continued on with her shift, seeing other patients… but her encounter with Mrs. Richardson continued to weigh on her mind. She wondered whether she should have responded differently, perhaps confronted the patient about her racist behaviour. She also felt angry and disappointed that Steven got the opportunity to learn and perform the procedure solely based on his race.

Nearing the end of the shift, Dr. Young noticed that Natasha was visibly upset and less engaged in her cases. He began to question how he had handled the situation. He wondered whether he should have said something to Mrs. Richardson, and if so, how he would have approached such a sensitive and awkward situation? Should he talk to Natasha again? Would she leave her shift feeling unsupported by her staff? How will this encounter affect her future interactions with patients?

Discussion Questions

  1. How should Dr. Young have responded when Mrs. Richardson refused care from a learner on a discriminatory basis?
  2. Should Dr. Young have allowed another learner to see the patient in Natasha’s place?
  3. Should Steven have advocated for his fellow trainee? If so, how?
  4. If Dr. Young had belonged to the group(s) being discriminated against (e.g. female, a person of colour), how would this have changed his approach to this patient?
  5. How should physicians respond when patients refuse care on a discriminatory basis in urgent situations or when no other providers are available?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

Our 3 experts for this month’s case will be:

  • Dr. John Neary
  • Dr. Brenda Oiyemhonlan
  • Dr. Teresa Smith

On October 13,  2017 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • Anand Swaminathan

    Unfortunately, many of us have faced this interaction many times. I’ll admit that though I’m a doctor of color, I’m not a substantial minority in my field and so, I face this far less than many others do.
    As faculty, colleagues and humans, we owe it to our trainees to support them and to address this issue head on. Our creation an alternate solution to the issue conveys an acceptance and says that this behavior is within the normal limits and it clearly is not. Racial, ethnic, religious, gender or sexual orientation bias has no place either in the hospital or in society.
    When I’ve experienced this directly, I’ve discussed with the patient that I’m the physician in charge and the most qualified to take care of them. If they aren’t satisfied with that, they are free to seek care elsewhere. I only use this approach if the patient is stable and doesn’t have a serious or life-threatening condition. If the patient is altered or is to sick to have decisional capacity, I continue with treatment. Stable, patients have a right not to have me as their doctor but that right does not extend to my workplace.
    When this happens to my trainees, I have the same approach. I let the patient know that this is the physician who is most qualified to take care of them with me as the supervisor. If they are stable, don’t have a life-threatening complaint or presentation, I let them know they are free to seek care elsewhere.

  • David Strauss

    Related to gender….how about the female patient that only wants a female provider to do pelvic exam?

    • This literally happened to a trainee working with me a while back! Luckily, I am female, but my learner was not. As a consequence, I told the learner to tell the patient the truth. They could wait for me (i.e. I was acutely resuscitating a patient and about to intubate them – so it could be at least an hour) or they could have him do it… I affirmed that the trainee was confident and competent at the skill (having just completed an Ob/Gyne rotation, he was both) and encouraged him to explain this to the patient.

      The patient, once empowered with all the the information and the choice, preferred to have everything done and over with… So with an RN chaperone, the trainee completed the exam in no time and the patient was actually very impressed with his technique. I arrived just in time to review the case after all the bloodwork was done and she was ready for discharge. When asked in retrospect… she was just worried he might not be empathetic or understanding – but he was both!

      So, I think having the discussion around this is very key – and also empowering the trainee whenever possible!

  • Viren Kaul

    As a resident, I heard about a particularly distressing incident that happened to my co resident. He was Indian and the patient who was stable, refused to talk to him and called him names best not repeated. His attending, a Sikh gentleman received worse treatment as he tried to reason with the patient and was ejected from the room. The patient was eventually assigned to another team.

    After the incident, there was a heavy feeling in our group of residents, a hurt that we couldn’t talk much about, a certain disappointment. Our attending did his best to stand up for us, so that wasn’t what bothered us. This was in years where the conversations were just starting and the institution also was a bit shook. Since then institutions have come together and so has the literature.

    However, there is a shock wave effect leading to collateral damage in the physician population. There is an unpoken disappointment and hurt. I can only imagine there is resentment towards being treated that way when all we want to do is deliver the best care. Who do you express your opinions and feelings to at such times. How do you reach out to an affected colleague? Should you reach out if they aren’t first? As trainees, how do you advocate for your equally qualified friend? How strongly does the teaching program come out in support, and how does the institution offer support to the affected parties? So many questions just hung in the air at that time. And I’m still looking for answers!

    • Anand Swaminathan

      It goes without saying that this is awful and I agree that the ripple effect can be profound.
      I encourage you to push your institution to embrace a no tolerance policy for this type of patient behavior. I am fortunate to work at a place that has done so: if the patient is stable, not altered, they can be escorted out of the building. This obviously would exclude the acutely intoxicated patient who is offensive and inappropriate but, is altered due to substance as well as those with other causes of delirium.
      Without institutional support, it’s hard to do this.

      • Viren Kaul

        It’s been years since this happened. And they did institute a policy, so progress!

        Guess to be specific: what can we do to address the downstream effects of such interactions on the physician morale?

        • Christie Lech

          This is definitely a multilayered issue that will take time and a unified effort. I do think that (thankfully) we are discussing a small percentage of actual patients that come through our emergency department doors.

          As educators and residency/medical leadership we must identify this behavior to our trainees as racist, sexist, ageist, discrimination based on sexual orientation, discrimination based on religious beliefs/practice, etc. This sounds simple, but the effects of this can be profound – think of how many times we hear a someone yell out a racial slur or demeaning language and we all do not say anything (or know what to say). After acknowledgment of this discriminatory behavior, it is important that all staff are trained on how to apply appropriate de-escalation techniques to mitigate the situation. Finally, after the situation reaches closure, it is important for staff to be debriefed and also have appropriate support resources to help them process reactions to this case and manage downstream effects.

          We ultimately are the last and only line many patients have for care and for advocacy. I am far from an expert in this topic, but from my review, the extent to which laws/policies such as the Civil Rights Act protects staff in the hospital setting from discriminatory behaviors from patients/visitors is unclear. No obvious precedent has been set in our context, although there have been cases in which the Civil Rights Act has been evoked around a patient care in other settings (nursing home). Those who have examined at the Civil Rights Act have stated that, in certain cases, the reasoning behind allowing patients’ requests for a physician of a particular race (race congruence) is not to discriminate against physicians but rather to optimize patient care. The huge caveat here is that this does not distinguish patients who requests originate from a space of bigotry and racism (which we are talking about) as opposed to being rooted in being a member of stigmatized/marginalized group.

          These interactions can and do impact departmental functioning, patient care, and trainee education. As such, I echo the other comments above and say that institutional leadership must address this. One beginning point may be: Starting with naming the particular incident, then stating: ‘We respect people of all ethnicities, races, gender, sexual orientation, age, religious beliefs, etc. We will support and protect all our staff and make every effort to prevent and mitigate situations of intolerance and discrimination.’

          I also invite everyone to participate on a national level on this and related issues through CORD. I developed a task force through CORD (Prevention and Mitigation of Workplace Violence) that will address this and other related issues.

  • Kaif Pardhan

    It is sad, but this is definitely a situation that our trainees and faculty encounter when they are a visible minority. This case certainly presents a challenge for all three physicians on the shift – Natasha, who is the subject of the discrimination, as well as her supervisor and her colleague.

    I have been remarkably fortunate in my career that, despite being from a visible minority group, most interactions that have to do with my ethnicity are more from a foundation of curiosity rather than hostility: “What an interesting name you have”, “Where do you come from? No where do you really come from?”. However, I can relate to Natasha’s story and I know how hurtful discriminatory statements can be. Platitudes such as “she’s old and set in her ways” or “it’s not your fault” ring hollow when your care is being rejected, not because of your qualification, but because of what you look like.

    This case presents an important dilemma for all physicians: We have an obligation to provide care regardless of a patient’s “race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth[,] other status” (Universal Declaration of Human Rights) or sexual orientation. However, physicians are not obligated to tolerate abuse or discrimination themselves from a compos mentis patient.

    In this particular case Dr. Young has a couple options other than the one he pursued:
    – Make the case “non-teaching”, see the patient himself, when time permits, and ensure that it is clear to the patient that racial discrimination is not acceptable in the emergency department. I would generally advocate for this approach in a patient who may have an important diagnosis that is time critical.

    – Inform the patient that a refusal to see a member of the healthcare team will mean that she will need to wait until the next team arrives. In this scenario, I would certainly advocate that appropriate analgesia be provided to the patient while they are waiting. This is the approach that I might use for a patient with a non-life-threatening injury.

    These are fairly sweeping solutions that may not apply in all scenarios but, as a rule, I would advocate for a protocol for healthcare workers to follow when patients refuse care for discriminatory reasons. This protocol might include the acuity of the patient’s problem, unrecognized secondary issues and co-morbid conditions that might impact their judgement.

    I think the critical scenario is the one addressed in the final question: what do you do if there is a life threatening emergency and the patient refuses care for discriminatory reasons. Again, I think the issue of the patient’s capacity is critical to this conversation. When there is no other provider available, and the patient demonstrates that they have capacity, it is important to continue to be kind, explain that you are the only provider and counsel the patient regarding the possible outcomes should they refuse care. However, if they wish to refuse care based on the colour of their provider’s skin, or for any other reason, that is their right. We always want to help our patients and their refusal of our services hurts and weighs on our minds, so it’s always important to debrief these cases with our team, including residents and medical students to ensure everyone feels supported.

  • This is a very important set of tweets that every physician interested in this issue should read – by one of my heroes @Esther Choo!
    https://twitter.com/choo_ek/status/896850427408293888?lang=en