The burden of discrimination can compound the stress of practicing medicine for physicians who are cultural and religious minorities. Hospitals have policies protecting against workplace discrimination at the hands of colleagues or supervisors. But when a patient is racist or biased towards a physician or other health care provider, there is often no recourse.

Through silence and inaction on this issue, hospitals may reinforce the isolation that clinicians of racial and religious minorities can sometimes feel in medicine. Particularly at a time when some Americans feel emboldened to speak and act in bigoted ways, clinicians need support managing patients who make derogatory and abusive remarks.

In the last rotation of my final year of medical school, I was asked to apply pressure to the femoral artery of a woman who had undergone cardiac catheterization to open her blocked coronary arteries. Since she was wide awake, and I would be standing next to her bed holding gauze firmly to her bleeding right groin for at least 30 minutes, I tried to break the ice by saying, “Guess we should get to know each other.”

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The patient was an elderly white woman who had spent 40 years teaching at a nearby suburban high school. She complimented me on making it to medical school and, without warning, gave me this advice: “Now, don’t waste your affirmative action.”

I was offended by her unspoken assumptions about my educational pedigree. What other presumptions had she made about me as a black American? In my head, much like a sitcom freeze frame, I imagined telling her off, delivering my curriculum vitae line by line as proof that I’d earned my spot in medical school and forcing her to acknowledge her racial bias. In real life, I just smiled and kept the pressure on her artery.

Patient bias can be even more direct. I recently cared for an elderly veteran who, after being introduced to my intern, a Muslim American female with a last name that highlights her heritage, offered his complete thesis on how Islam was ruining the world and that all Muslims are terrorists. Although she was insulted, my intern did not confront the patient. After we had finished admitting him to the hospital, we commiserated on similar experiences. We used his age and possible post-traumatic stress disorder to soften the blow of his bigoted candor. In spite of his commentary, we cared for him competently and respectfully, just as we care for all of our other patients.

In the days following that encounter, I asked my colleagues if they had ever experienced anything similar. A Vietnamese physician told me about being called a “dirty incompetent g**k” by an angry patient experiencing alcohol withdrawal. During physical examination, a colleague discovered a large swastika tattooed on the back of her patient. Another was told by a patient that he looked more like “a common street thug” than a doctor.

A 2011 survey found that among 377 family medicine trainees, 35 percent experienced intimidation based on race, gender, or culture during their residencies. Recusing oneself from the treatment team is an option for some physicians, but most of those I spoke with ignored the racist or derogatory comments and kept working.

Guidelines for managing patient prejudice are hard to come by. A 2016 article in the journal Academic Medicine suggested a four-step approach for physicians confronted with a patient’s racism: 1) ignore such comments in an emergency; 2) focus the encounter on the shared goals of treatment; 3) depersonalize the event; and 4) foster a community of support within the hospital.

A New England Journal of Medicine article, “Dealing with Racist Patients,” offers an approach that incorporates consideration of the patient’s decision-making capacity and an attempt to understand his or her reasoning when, for example, a clinician of another race is requested. There are, after all, nuanced distinctions between patients who refuse care based upon a practitioner’s race for reasons rooted in bigotry and those who make similar requests based on religion or culture. Some data suggest that religious and cultural concordance between patients and their health care providers is associated with increased patient satisfaction, comprehension, and trust.

While that makes sense, it seems disingenuous to retreat to protocol without addressing the harm that a patient’s bigoted comment can have on a practitioner. Racism in medicine has been identified as a stressor for African-American physicians, and it is not a stretch to say that the distress caused by patients’ racially charged commentary may contribute to burnout.

Some degree of ignoring such comments and “rising above” the situation may be warranted to maintain workflow and professionalism. Yet physicians should also have the right to work without being targets for verbal abuse, threat, and intimidation based on race, gender or religion.

At its extreme, some have suggested racism could be included in the Diagnostic and Statistical Manual of Mental Disorders (sometimes erroneously called the bible of psychiatry) as a psychiatric illness of delusion. If we extend this logic, then doctors have a requirement to diagnose and treat racism when it presents in their exam rooms in order to prevent harmful acts by deluded individuals against targeted social groups.

If my colleagues and I err by ignoring patients’ bigoted comments or actions, then what should be the appropriate response? The answer isn’t simple.

Many institutions have committees on social medicine, multicultural affairs, or diversity and inclusion. Through the efforts of these groups — often led by minority physicians and students — teaching hospitals have integrated cultural awareness and sensitivity training into medical education. Such training has focused on coaching physicians to examine their own biases and how they influence patient care.

These are important steps in the right direction, but they alone aren’t enough. Medical education has fallen short in modeling the dialogue between health care providers and patients about patient-held biases. The result? Minority health care providers are often silent about their experiences with racism, religious discrimination, and other forms of bigotry in medicine. Majority providers, when they witness such acts, often fail to intercede on their colleague’s behalf.

In an ideal world, hospitals would categorically disavow cultural and religious discrimination. Hospital administrators would publicly refuse to cater to culturally biased demands and express a lack of tolerance for derogatory comments towards physicians and staff as a part of patient non-discrimination policies. All health care providers would receive training on how to facilitate dialogue that can productively challenge a patient’s racist or biased behavior. Hospital support networks would exist so minority providers could candidly discuss moments in training and practice where they’ve felt discriminated against.

The conversations we must have with our colleagues and patients are difficult and uncomfortable. Yet openly discussing bias is how we will put pressure on hospitals to consider how policies can be revised to better support minority physicians who are victims of demeaning remarks or actions. Our ethical responsibility to provide unbiased clinical care to all comers makes hospital administrators unlikely to take on this issue without pressure from physicians and other providers.

We will never eliminate racism and religious discrimination, but we work diligently to — at the very least — ensure that our hospitals are safe and affirming environments for health care providers to discuss how cultural and religious differences affect how we are perceived and treated by those whose lives we have sworn to save.

Lachelle Dawn Weeks, MD, is a resident in internal medicine and chair of the Social Justice Committee at Harvard-affiliated Brigham and Women’s Hospital in Boston.

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  • And then there is the other direction. What about the patient’s comfort? They are bigoted, but they still feel uncomfortable by being treated by someone they have their bigoted views on. To move from the triggering topics to something more harmless (nevertheless bigotted): Assume a muslim refuses to be treated by a christian doctor. What should the hospital do? Should they let him die for begin too bigoted or should they try to get one of their muslim doctors and the christian one treats the other patient meanwhile? There must be limits what they need to make possible, but some wishes should not be denied and still they should try to rescue the person when its possible under these circumstances. And probably rescue him violating his beliefs when its not possible.

  • That’s why health care providers are taught to avoid controversial topics of conversation. I think this article is about patients taking offense to something about you that cannot be hidden.

  • Since I’m a political libertarian, I tend to support more ‘conservative’ politicians than ‘liberal’ ones, and there is ALOT of bigotry and hatred out there….!

    One of my liberal and gay peers tells me that even the most ‘redneck’ patients generally treat him well, but many of my conservative peers tell me they constantly face hateful remarks from their peers, and from any patients who learn they aren’t Democrats.

    I’ve had several ‘liberal progressive’ patients who said very nasty things upon merely seeing medical journal articles I’d posted in my exam rooms that supported free-market health care. One who runs a ‘non-profit’ organization that helps people with the proper skin color told me that my support of free-market health care meant I was just “getting rich off the backs of poor people”. I was going to politely change the topic, but decided instead to ask her how much she was paid to run her nonprofit organization – it turned out she was making more than twice what I did per hour, so I am glad I did a bit to EDUCATE her as to economic reality.

    Too many times hatred and divisiveness is tolerated, as long as it comes from the political left.

    • I think the “particularly at a time” comment was an allusion to the ‘fact’ that Trump is bigoted/racist, and so are his followers. You know how ‘divisive’ things are now, so that is of course Trump’s fault, and has nothing to do with who occupied the White House for the past eight years….. LOL…

      It isn’t courageous to ‘fight bigotry’ when one selectively defines it, and only admits it exists in one direction; ALL BIGOTRY IS WRONG. So is ALL initiation of violence. So is vandalism and theft, no matter whether the victim is of a ‘protected class’ or not.

      The only thing Trump caused is some HOPE for CHANGE (irony of word choice intended); those on the moderate-to-right part of the spectrum are beginning to feel they no longer have to hide their political views for fear of attack (verbally, physically, and on-the-job, particularly in ‘academia’). Unfortunately as they speak out, they are finding they are STILL prone to attack; funny how the progressives who jump on any (even imagined) ‘hate’ against the political left, seem to ignore or dismiss any attacks on the political right. The only reason the baseball shooting made the radar was it was so blatant and couldn’t really be blamed on anyone but the shooter (although I’ve heard several liberal physician colleagues say “the Republicans deserved it – they are so violent and hateful themselves”). I reminded one of my peers that the only KKK member I ever personally knew was a Democrat politician, and she hasn’t spoken to me since.

      Fascinating political times, eh…?

    • AJMD- Thanks for clarifying cause I thought the author was talking about the race baiter we had in office from the prior 8 years.
      Speaking of affirmative action ……
      The authors states “She complimented me on making it to medical school and, without warning, gave me this advice: “Now, don’t waste your affirmative action.” I was offended by her unspoken assumptions about my educational pedigree.” so, lets see …. you want to “check the box” and get into medical school with lesser qualifications because you are a historically “undeserved minority” Yet you get offended when someone assumes that that is the case??? Seems to me you cant have it both ways. Isn’t that exactly the problem with affirmative action??

    • Interestingly, the (mostly-white) people I know who own small businesses could care less what race (or religion, or gender, or sexual orientation) someone is – they care only about ability and integrity. It’s only my liberal friends (who, being anti-capitalist, seldom own businesses) who seem obsessed with ‘classifying’ everyone as to race, gender, income, sexual orientation, and religion, AND TREATING THEM DIFFERENTLY because of those characteristics.

  • What does this sentence mean “Particularly at a time when some Americans feel emboldened to speak and act in bigoted ways” what time are you referring to I wonder?

  • This type of behavior toward doctors, nurses, orderlies, and other medical personnel who are cultural and religious minorities merely underscores the inherent pathology of bigotry. What person in his/her right mind would insult people who are the last line of defense between him/her and suffering or even death? As my mother liked to say, “Don’t cut off your nose to spite your face.”

  • I’m a Personal Care Aide, sometimes for 12 hours a day I’m sitting with a patient and their family. At least once a week I see some form of racism against doctors, nurses, really any staff member that is not white. It shocks and horrifies me, especially if the patient is under 50 years old (I’m 43). I try to kindly remind them that if the knowledgeable staff hadn’t been here to take care of them they wouldn’t be alive.

  • There was a scene in Trauma: Life in the ER where a black woman only wanted a male physician. The clinician told her that would be fine, and put her at the end of the queue. Seems a good way to deal with the problem as long as the person isn’t bleeding out or is not in their right mind due to low blood sugar, TBI, etc.

  • I’m a PA-C for a hospitalist practice. For reference, I’m white. I was admitting a patient one night and at the end of our encounter I explained that I would not being seeing him again, but that one of the physicians in our group would assume his care in the morning. He responded, “Not that brown guy I had last time, right? I want an American.” I responded, “I don’t know which of the board-certified physicians in my group will be seeing you for the rest of your hospitalization, but I assure you that they are all equally qualified, passed the same board exams, and will care for you regardless of their skin color or yours.” He did not have a snappy reply….

  • As a white nurse, I encountered a lot of very nasty racism on the part of black pts, who were especially ugly to Asian nurses. One of my first pts was a young black guy who made an incredibly obscene, ugly remark to me while I was wiping his butt. It was not the last time I heard such comments, and often from black aides, too. Now and then, a pt would request a black nurse, saying “I don’t want white hands touching me.” If you think prejudice is a one-way street, think again.

    • Thank you for your comment Roxanne. Surely people of all races and backgrounds can be prejudiced and make rude remarks – I don’t think anyone was implying otherwise. I’d ask you to consider the perspective of a practitioner from a marginalized social group experiencing racial or religious bias and feeling potentially as though they have no recourse for managing it or discussing it because of the social implications of discussing race/discrimination in the workplace (specifically in medicine). Consider the isolation and invalidation a minority practitioner feels and how it compounds with daily experiences in a society and profession that is also isolating and invalidating. That is the perspective from which I wrote this piece. Again thanks for reading and I hope you’ve found outlets within your hospital to discuss your feelings about the experience you had.

  • Thank you for a nuanced and thoughtful on this subject. I am an occupational therapist who has worked in home care for many years. Unfortunately I have heard patients make racist remarks directly to me, a white person, regarding a health care provider, usually a home health aide, who is present in the room. I have tried ignoring the remarks and re-directing the conversation, but while this meets the standard of care for patients, it does not address the insult, essentially a form of abuse, to the provider. I have found that gentle correction to the patient on behalf of the provider is well received by both, and allows us all to proceed with treatment.

    • Please suggest the wording of a “gentle correction.” It’s so hard to articulate things diplomatically when my back is up.

    • I have sometimes pointed out how caring, hardworking, and qualified the aide is. I have also said that we providers do our best to treat everyone well, regardless of their color, views, etc., and we hope the patient will do so also. Ultimately our agency director decided the patient does have the right to ask for another caregiver for any reason, but we should make it clear it may be a very long wait until someone who meets their requirements is available! I also believe under some circumstances the provider should be allowed to refuse to treat a certain patient.

    • Thanks for speaking up when you can! It is very important that allies speak up when they encounter racial and religious bias/discrimination. Training on how to offer that “gentle correction” in a way that addresses abuse towards physician in a way that is productive and doesn’t compromise patient care would likely be beneficial to providers (minorites and allies both)

    • Cameron,
      From one OT to another, thanks for sharing your experiences, and for having the backs of your coworkers while also providing a valuable lesson/education to your patients! I am white, and I worked with the greatest OT, which happened to be from the Philippines. She had this patient, a white guy in his late 40’s with a TBI. We worked on a small hospital rehab unit. One day a white PT came to ask me if I’d ask my fellow OT if we could swap patients so I could treat this man instead. I asked her why she wanted me to ask her that, as she hadn’t herself mentioned anything to me. The PT told me, “Well, he works hard for me, and I don’t think he works as hard for [my coworker from the Philippines] because she’s Asian”. I asked if the patient had said something mean to my coworker, or if my coworker confided in her that she needed some sort of assistance, and the PT admitted that neither had actually happened. She had created this whole theory in her own head. Maybe he didn’t work as well for her because he just spent 90 minutes exercising and walking with you prior to his session with her? Maybe he was tired or feeling extra bad that day? Maybe he actually was a racist? I didn’t appreciate her assumption, or the fact that she thought that I would just swoop in and approach my peer like, “Hey! We think John Doe will work harder with me than you, because I’m white and you’re not, so we’re gonna swap, ok?” I told her if my peer was having any problems, she was welcomed to talk to me and we’d work it out. Later that day, I casually asked my coworker how her day was going, and if she needed me to help her out with anything. She happily told me she was having a fine day, then asked me how I was. I didn’t get any sense that she was having any issues with the guy. We were pretty close, and I had oriented her to our facility upon her move here, and always told her to come to me if there was anything i could help her out with. Nothing ever become of any of it, and I still don’t understand how an educated, professional person could be so backwards as to create such a theory in her own mind, and then expect me to act on it (this wasn’t the first time she said or done something like this). Maybe she wanted to feel superior because of our whiteness? Maybe she was genuinely concerned? Maybe she’s just kinda nutty. I’m just really glad I didn’t feed into it and approach my colleague that day. Had I done that, I possibly could had damaged her self-esteem and confidence. It’s hard to tread that line between defending a colleague, or possibly taking away their opportunity to use their own voice when they are poised to address the issue themselves. I’m no longer at that facility, and I really hope my former peer isn’t having to tolerate any racism (real, or imagined by someone else). I hope to always be able to make good choices when it comes to supporting my friends and coworkers in any way they need it, or to have the wisdom to take a step back and support them in their use of their own power and voice in advocating for themselves.

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