post

Any Place for Race on the Coalface?

Last month (Feb 25th 2016) the New England Journal of Medicine published this editorial “Perspective” titled: “Dealing with Racist Patients.

In the article the authors – Drs Kimani,  Alexander K. Smith, Bernard Lo  and Alicia Fernández present this case vignette:

A 77-year-old white man with heart failure arrives in the emergency department of an urban hospital at 3 a.m. with shortness of breath and a fever. When a black physician enters, the man immediately announces, “I don’t want to be cared for by a %$#!{& doctor!” Taken aback, the physician retreats from the room. She’s offended by the man’s rejection and demeaning language — but knows that he may have a serious medical condition and that she cannot treat him against his will. How should the physician proceed?

This is followed by a discussion around the ethics and legalese aspects faced by physicians when dealing with overtly racist patients in the ED.

There is even a flowchart to assist the decision-making around this scenario.  Probably a good idea to have a “checklist” when dealing with a potentially emotional and heated discussion.

Please have a read of the article and come back here for my thoughts.

Last week I had the chance to discuss this paper and the issues raised with a few of my colleagues – and there were some interesting opinions.  To give you some context our ED is very much an Aboriginal ED – about two-thirds of our patients are Indigenous Australian people.  Our staff include a mixture of local, Anglo/European Aussies, overseas-trained doctors and our fantastic local Aboriginal health workers.  Being racist is not really an option if you work in the Kimberley – or at least it would be a very unpleasant existence. We do see a bit of “reverse racism” particularly directed at our overseas-trained doctors.  So it was interesting to read this article and see how it works in the U.S of A.

The authors of the paper broke down the ethical considerations based upon the patient’s reasons for refusing a particular doctor

  • Incompetent patient: – clearly these folk need to be treated under a duty of care. Don’t see much to gain by fuelling a conflict in this scenario.  If a patient does not have capacity to make decisions then it comes down to the family.  I would tend towards uber-pragmatism here and offer whichever physician will cause the patient the least distress.  But… Racism on the part of the family should not be included in this compromise.
  • Patient preference based on “clinically or ethically appropriate reasons” – this is a little bit tricky.  Examples are given:
    • Female patients requesting a female doctor.  (This is often the case in Aboriginal Health in Australia – it is generally culturally inappropriate for male clinicians to perform intimate examination of female patients [and vice versa].  There are of course degrees of ‘intimacy’ and traditional beliefs.  We also have varying capacity to accomodate this scenario – I work solo nights, so cannot offer this at all times.)
    • Patients who request clinicians with same language.
    • Patient with negative experiences with a particular racial group – e.g. veterans of war conflict rejecting clinicians from their former enemy country.
  • I would add another group of patients that I have come across; patients that request a different clinician based upon “undisclosed” reasons… for example a homophobic patient may refuse to see a doctor that they suspect to be a homosexual.
  • Finally there is the overtly racist or bigoted patient.  These are somewhat easier to classify, however the conflict is usually front-and-centre.

The authors also raise the potential for conflict between the patient’s wishes and the employer’s [hospital] duty to provide a safe and non-discriminatory workplace.

Of course, being the USA there is alway the potential for physicians to take civil legal action against these patients.  This hasn’t happened yet.  I cannot imagine it happening in Australia  – but it does raise another set of ethical questions.  Should a physician take legal action against a patient in this setting?  Certainly we pursue criminal charges in the case of staff being assaulted.  How is this different ethically?  Is a verbal “assault” based on race, gender, religion or sexuality different if a punch is never thrown?

So after a bit of debate and thought I have boiled this down to two basic options in my head.  If I was in this situation there are 2 practical options:

  1. Acquiesce to the patient’s request and provide another clinician
  2. Decline the request, run the risk of conflict, but remain “ethically intact”.  That is, place the principle before the patient.

So how to decide which way to play any given scenario…..

For me the central, critical question is around the underlying patient motivation.  You might ask yourself the following questions:

Is the patient refusing a particular doctor in a genuine attempt to enhance their own care?

OR

Are they placing their care behind their irrational, false belief that the treating doctor is in some way inferior.

So put yourself in this situation:- you are the duty consultant and a patient is kicking up a bit of fuss after being allocated a doctor who was trained in Pakistan.  The patient has no other information about the junior doctor other than his name – Dr Mohommed Hafeez Bilal and that he has a strong Pakistani accent.  The patient doesn’t appear to have a life-threatening condition but it is looking like he will need admission for ongoing investigation.

Q1. How will you deal with this patient?

Q2. What will you tell Dr Bilal?

Q3.  Do you have another, smarter way of breaking this down?

 

Comments

  1. I don’t see how the underlying patient motivation is relevant, especially in a publicly funded cab-rank system. For example, if a patient refuses any doctor who is not a FACEM seeing them in emergency, is that appropriate?

    In the context of the four hour rule and similar KPIs, how should patient refusal of a particular doctor be factored into this? As an anecdote, I was once asked (when working night shift in ED) by a male colleague to see a patient with abdominal pain whose husband had requested a female doctor. I said that I would see them as appropriate, behind all the other people who hadn’t already given up the chance to see a doctor.

    I think that’s the only appropriate way to handle this sort of situation -- if you refuse the first doctor that you are allocated, you go to the back of the queue and wait your turn until your number comes up again.

    • Do you have a policy for cross-gender examination of Aboriginal patients? For me this is more about respecting patient culture and empathy than actual racism.
      Certainly the “make them wait” option was popular in the poll of my colleagues and it has the appeal of avoiding immediate conflict, but is it the ethically correct thing to do?
      Not answering, just asking.
      C

      • I don’t have a policy -- I see patients as they come, and if they don’t want to see me, then they don’t get to see an inpatient registrar.

        The other option, of course, is to scan first and ask questions later -- if they have a positive CT scan, they’re usually willing to see anyone; and if they have a negative CT scan…

        • Respectfully, I have never understood the “they can wait again” approach. They already have waited. This serves no other purpose than to punish the patient who may simply be acting in accordance to norms dictated by their belief system. This is especially true in the context of same gender provider performing pelvic/breast exams.

          If the provider is a person of faith, or from a more traditional background, they probably have an easier time sympathizing with the request. On the other hand, the physician who has no religious values in common with the patient may not be sympathetic, but would perhaps consider the patient to be a victim of her environment. And in that case, wouldn’t sympathy also be in order?

          I think the answer to Casey’s question to Hildy about ethical appropriateness is that we are required to accommodate this specific request to the best of our ability. This is a non issue if there is no suitable physician immediately available or if working single coverage. I definitely don’t mean that the next provider has to rush to the bedside, but barring sicker patients, this should be the next patient to be seen. Placing our own metrics ahead of patient autonomy and self determination seems to me to be placing policy ahead of patients -- and that would be wrong. Now, I am speaking as a male so I’m not the one who gets these calls (though I speak an often needed language in our ED and so am called sometimes to see “extra” patients), but I sympathize with the added strain. On the other hand, I practice in a busy ED with large Muslim and orthodox Jewish communities and I don’t have to ask my female colleagues to take over very often. When it does happen, my approach is pretty similar to the algorithm described. If a female physician happens to be on I will explain to the patient that she might need to wait a little longer (generally not a problem), then I would ask my colleague. If she agrees, fine. If not (or if none are available) I’ll explain the situation and offer to perform the exam myself. In many cases the patient will then acquiesce, having done everything to adhere to religious norms. However, they often may not and, as we’ve already established their decisional capacity, I will review risks of refusing this portion of the care, and document appropriately in the chart (including assessment of capacity). Seems to me the best we can do.

          Finally, I am not sure we need to be doing as many pelvic exams as we do and as is considered standard practice (at least in the US). Part of this problem may be obviated by utilizing these sensitive examinations only when they would actually change the clinical course in the ED -- just as we (should) do for any lab or imaging test.

          • In an Australian context, it comes from the notion that public patients do not get choice of provider; and since they do not pay monetarily, they pay by waiting. If they’ve ‘paid by waiting’ and don’t like the first provider they get, they can pay again and roll the dice again.

            My other objection to this is that it biases the patients I see toward a particular patient mix that I might not be interested in. So seeing all the breast and pelvic exams might mean that I get fewer of the critically septic patients, or the traumas, etc. It becomes poor training for me.

            I don’t mind doing a specific examination, but when the complaint of the patient is that they don’t want to see a male doctor at all (even for history, etc), I am not very happy.

  2. Great Q Casey. I have seen this also in the context of religious intolerance. It is interesting how I am more willing to accommodate patients when their intolerance is based on cultural or religious values, but less so when it is based on racial and political ideologies.
    My approach would be and has been the following. I think it is clear to identify the victim here, and it is not the 77 year old patient in florid CCF…. It is Dr Bilal. And it is precisely the point when the hospital acquiesces to the bigots demands that Dr Bilal becomes the victim.
    It is the victim that must be supported. I would empower them by asking them how they would like to proceed. And support them in their decision.
    The first path- where Dr Bilal treats the patient, is the most difficult and least trodden. The potential risks are considerable: an escalation of abuse, refusal of treatment by the patient and purposeful substandard treatment on behalf of the Dr leading to potential adverse outcomes and legal proceedings… But the benefits are also great. It is an opportunity to show how a great Dr (like Bilal) can overcome the prejudice projected against him and perform his duties in the face of adversity. It would show Bilal ethical and moral superiority and potentially provide an opportunity for the bigot to change his ways (at least in the case of Bilal). One would of course need complete confidence that the Dr is willing and capable of performing at this level under these extremely difficult conditions- but they would be empowered.
    The easier path is the one most often chosen where another doctor attend the patient. Unfortunately even a brief statement reiterating your hospitals policy against racial intolerance is only paying lip service, given that you have conceded to his unreasonable demands. Still, it is the victim who has chosen how to proceed, and not the patient, and Dr Bilal can still enjoy the full support of the hospital.
    It reminds me of an interesting story from a colleague of mine who used to work in the Kimberley. A patient refused treatment from a female nurse on the grounds that she `looked butch and didn’t want to be treated by a lesbian`. The nurse was not a lesbian, however she handed the patient care over to her petite colleague. On departure the patient was extremely complimentary about the care she had received from her nurse and departed. That night the petite nurse went home to her gay partner with a smile on her face!

    • Thanks Tor
      I like the approach -- placing the doctor at the centre and allowing them to choose / empowering their decision.
      Practical yet empowering
      Out of interest -- refusing care on the basis of sexuality is troubling… especially in modern care where LGBT staff are common, they are the new norm in recent years.
      But irrational is immune to rationality…

  3. some interesting thoughts here. It’s clearly not so black and white in real life, but a small anecdote from my experience.. As a student in the UK I once had a patient be racist and verbally threatening towards me. It wasn’t as much a dilemma as I obviously had no responsibility. But on debriefing later with both experienced nursing staff and a consultant, I was told that as racism is illegal, the patient has no right to make such requests, and that -- after ensuring support from seniors and nursing staff -- that should i face this situation whilst working, I should present this to the patient as such (thus leaving them with me or the door). The exception being life threatening disease, in which case one presumes the patient would be less likely to refuse (or be too obtunded to).

  4. Michelle Johnston says:

    Such interesting ethical issues here. You raise extremely illuminating examples in your post -- listing the cultural concerns of the Aboriginal patients alongside those with experience of military conflict, right up next to homophobic people. I think the answer lies right here. After 26 years in the public health service, I have given up entirely on forming overarching opinions. Every individual case ends up being utterly unique. Patient motivations are rarely in the purely right or wrong camp (and are oft-times too complex for us to work out in the short space of time we have with them). Arguing about one individual case probably has little ramification for the next.
    Once a patient is in the ED, other confounders come into play -- fear, illness, intoxicants, disempowerment etc, and we frequently find people behaving in ways they wouldn’t in the outside world. Thus, sadly, this seems to be the rub. Short of actual violence, we tolerate behaviour in the ED that would not be acceptable out on the street. It may not be pretty, but that’s just the way it is.
    Absolutely agree with Tor, that there needs to be support of the victim.
    Once again, it reinforces that this job is not for the faint-hearted. When I hear critical care staff being referred to as superheroes, it’s not the cracking chests that come to my mind, it’s the ability to put aside one’s own personal feelings, and deal with every patient in front of you with as much respect as you are able. Part of that means trying to understand where they are coming from, and what they want, even if it stinks 🙂

  5. This has happened far to often to me and my colleagues (residents and attendings alike). I’ve been called so many racial epithets I can’t keep track any longer. To me, it’s quite simple:
    If the patient lacks competence, do whatever is necessary to care for them. Chemical cooperation is frequently necessary here. In patients who are in any way unstable or sick, I pull the trigger on RSI fairly quickly (common scenario is head trauma with intoxication and question of ICH).
    If the patient is competent and stable with this type of behavior, I simply excuse them from the Emergency Department to seek care elsewhere. It is unacceptable for physicians, nurses, PAs etc to have to tolerate such behavior. How am I to know that this hate is accompanied by a weapon (a frequent concern for us in the US, unfortunately). I quickly have patients like this removed from the ED with security for both the mental and physical safety of my team.

  6. Thought provoking questions Casey, thanks for posting. Now I am going to try to be brief…

    1) I generally approach these situations as outlined in the article: If the patient clearly does not possess decisional capacity or is in extremis would attempt a brief negotiation and then do what it takes to treat the patient, up to and including the use of chemical means. However, for the stable patient who is refusing care, I would first examine the patient’s reasoning (this goes also towards a determination of decisional capacity). In order “to play ball” though the patient must be willing to discuss and provide a rationale for their request (from my ethical viewpoint, legally this is probably not the case since a patient has a right to choose their physician when alternatives exist, or refuse to be seen). Of course there is a tremendous degree of subjectivity here and, as Michelle points out, often not one absolutely right answer, only a situational one. Bigotry is never a justification. Arbitrariness is, in my mind, also never an answer. But what of the WWII veteran who was tortured as a POW in a Japanese camp? Or the holocaust survivor who will not be seen by a doctor with a German name? The Turkish man who lost his son to a Kurdish extremist bombing? Or, as is implied in the article, the African American woman whose family has been victimized for generations and who is unwilling to see a “white” doctor? There is room for exploration and negotiation in all of these, and an infinite list of other hyoptheticals. A refusal to be seen by a certain individual should never be met with dismissal. It should first be engaged.

    2) Yes, Dr. Bilal should be viewed as a victim in this and should be given highest priority. I recently went through a similar situation when a patient accused me of being racist because I asked her to wait with the rest of the patients , while attempting also to address her clinical concerns. She felt I treated her differently just because she was black and then refused to be seen by me. Despite my attempts to engage I couldn’t get anywhere and in that case deferred to another provider. This worked out best for the both of us since I could not get to the bottom of her rage towards me (and felt crappy for the next week) and she was able to get appropriate care with what seemed to be successful deescalation. It is important to explain to Dr. Bilal (and I had to remind myself of this as well) that the patient’s biases likely have nothing to do with him personally and are based on a lifetime/generations of experiences. The patient’s reaction is more realistically seen as a form of transference than a personal reflection on Dr. Bilal. These episodes can be very defeating, especially given all the other stressors we deal with and the already high likelihood of burnout among emergency physicians. Reaffirmation and close support + follow up can go a long way. It also means a lot to hear this from supervisors and administrators, as we often fear they may not be on our side It would indeed be impressive if Dr. Bilal could take the moral high ground and engage directly with the patient then continue to provide care. This is often more trouble than it is worth and so, I think, most of us would opt to defer to another doc or to remove the patient from the ED altogether if stable and bigoted. We have a professional responsibility to one another and can never forget that. One final point -- this last step is limited in the U.S. by EMTALA. EMTALA overall is a very positive measure and one that provides much needed protections, especially to disadvantaged patients, but it does require that ED’s stabilize and treat all comers. I am not sure what the legal implications would be if a stable patient were removed from the ED against their wishes and prior to a complete eval just due to refusal to be seen by a certain provider.

  7. Geoffrey Menzies says:

    The triage nurse has often shown the really bad ones the door before I get the chance to exercise my humility and winning ways. This can indicate chocolates at the end of the locum. Team before patient.

Speak Your Mind

*