“Idon’t want your kind taking care of me!”
To an outsider, it might have resembled a standoff from an old Western. But it was taking place in a most modern hospital: the patient, an older white man hunched over with a snarl distorting his face; the physician, a young woman with a patterned hijab wrapped around her head.
Minority physicians like me often hear patients make “your kind” remarks. In a collaboration between STAT, WebMD, and Medscape, 59% of 822 physicians surveyed reported hearing an offensive remark about a personal characteristic from a patient; the majority of these remarks centered around race, gender, ethnicity, and religion. Another 49% had patients request a different doctor based on some of these characteristics.
In today’s climate of unbridled bigotry, some patients are becoming increasingly vocal in their disdain for physicians who don’t resemble what they perceive to be the norm: a white Christian male or female. It often translates into refusing to be cared for by a physician based on personal attributes like skin color, beliefs, and values — none of which have any bearing on the quality of care delivered. (Although this kind of racism or overt cultural fear is also directed against nurses and other health care providers, I focus here on the group I know best, physicians.)
I believe that openly voicing these prejudices originates from viewing health care as a commodity, a menu of services from which patients can choose the design and packaging of the care they desire. As a result, some patients feel entitled to dictate every aspect of the service, including their physician’s gender, race, or religion. But the key assumption underlying these choices — that the type of physician they prefer will provide better care — is not generally true.
Most physicians placed in the uncomfortable position of responding to requests like these defer to their promise to put patients’ needs first as encapsulated in the Hippocratic oath we all swear to uphold. But in giving in to prejudicial ideology, we also compromise our moral conscience because we know that such acquiescence is wrong. Providing healing while tolerating hate speech or discriminatory remarks and behaviors also erodes the basic tenets of the medical profession.
Acceding to such requests may also be driven by the competitive landscape of medical practice, in which metrics such as patient satisfaction scores influence reimbursement and promote an environment that I believe creates incentives for physicians to pander to patients’ requests.
In the United States, white is the predominant hue of the physician workforce. Blacks and Hispanics comprise nearly one-third of the U.S. population but don’t make up anywhere near that percentage of physicians. In addition, a growing number of U.S. physicians are Muslim. The historic whiteout of the profession is so ingrained in the American psyche that the expectation of white and black patients is to be cared for by a white physician.
Patient advocates might argue that patients should have a right to choose the kind of clinician they see, and denying them this right infringes upon their agency to make personal decisions about their care. But I believe there should be limits to the choices we give patients.
No one really knows if choosing a physician based on shared beliefs or values influences the quality of the interaction. If it truly improves patients’ trust or confidence in the care they receive and helps them follow their management plans, then it might be worthwhile to honor such requests. But if it doesn’t, then health care providers should engage in open dialogue in hopes of educating patients and providing them the best care.
Of course, not all requests for a different physician are expressions of prejudice or discriminatory ideology. A male patient may, for example, request a male provider because he feels more comfortable having a male perform an annual prostate exam or discussing sensitive concerns such as sexual dysfunction.
But what do we do when these requests are made in a different, more hostile spirit?
Unfortunately, the medical profession offers little guidance for how clinicians should handle blatantly discriminatory requests or comments from patients, leaving us ill-equipped to address such situations.
An article in the journal Academic Medicine offered a three-step approach for physicians faced with racism that included first assessing the severity of the illness or injury, then trying to cultivate a therapeutic alliance with the patient or family, and depersonalizing the event. But these provide actions to be taken after an incident has occurred. While workable, this approach puts the onus on the health care provider and does not hold patients accountable. It also does nothing to create an environment in which discriminatory attitudes, remarks, or behaviors are not tolerated.
It is time for the medical profession to do more to increase awareness among nonminority medical professionals of the challenges faced by their minority colleagues so they, too, can join efforts to advocate for change and help bolster a sense of belonging for minority physicians.
Acknowledging the problem of patient racism and making all practitioners aware of how common and harmful it is are the first steps. Beyond that, comprehensive curricula are needed for all trainees and health care providers that equip them with the knowledge to recognize discrimination in the workplace and what to do when it rears its ugly head. In addition, their medical institutions must stand ready to support them.
Deferring to a society still haunted by ghosts of its discriminatory past will hinder efforts to create and maintain a diverse workforce and an inclusive work environment in medicine.
Intolerance towards minority groups may sadly be the norm in our society. But in the hospital or clinic, intolerance towards such prejudice should be our unified response.
Uchenna Ikediobi, M.D., is an assistant professor of medicine in the section of general internal medicine and infectious diseases at Yale School of Medicine and practices medicine at the Veterans’ Administration Medical Center in West Haven, Conn.