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.

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

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