Dorothy R. Novick is a pediatrician in Philadelphia.
Patients refuse care based on health-care providers' ethnicity and religion so often that this phenomenon has been dubbed "medicine's open secret." A new poll shows that a majority of health-care professionals say they have faced prejudice from patients. In 2013, a nurse in Flint, Mich., sued a pediatric intensive care unit after it granted a request from a father to enter "no African American nurses" on his infant's care plan. Damon Tweedy, an African American psychiatrist, describes similar experiences in bruising detail throughout his memoir, "Black Man in a White Coat." And when Esther Choo, an Asian American emergency department physician, tweeted last month that white nationalists refused her care, she set off a Twitter storm of health-care providers responding with similar stories.
Patients have the right to choose their own health-care providers. But two challenging questions emerge when a patient refuses care based on a provider’s religion or ethnicity.
First, how do we balance the patient's right to determine his or her care with the provider's obligation to treat? Kimani Paul-Emile, professor of law and biomedical ethics at Fordham University, coauthored a practice guideline in the New England Journal of Medicine on this issue, recommending that if a patient is either medically unstable or has impaired cognition, the assigned professional is obliged to provide care. However, if the patient is medically stable and has decision-making capacity, the provider should attempt to negotiate, inform the patient that harmful speech is not allowed, offer transfer to a different facility and if all else fails, accommodate the request. This guideline and others ensure that we provide appropriate medical care to all patients regardless of their biases.
Second, how should we as health-care providers productively discuss the harmful effects of prejudice with our patients? Many of us deal with racism the way we have been trained to deal with politics in the exam room, which is not at all. We wear stickers declaring “I voted today,” but never for which candidate. In November, I cared for a 10-year-old who was fighting in school over the results of the presidential election. I treated his scrapes and redirected the discussion to nonviolent strategies for anger management. We understand that engaging in political discourse can distract from medical treatment and sour the relationships we work so hard to build.
However, by extrapolating this tenet to expressions of racial hatred, we miss a crucial opportunity for therapeutic intervention. When I treat racist patients but fail to adequately address the effect of their words and actions on my colleagues, I not only avoid teachable moments; I condone hate.
Pediatricians are in a unique position to address harmful behaviors in children. We approach these behaviors the same way we approach strep throat — overtly, with empathy, and based on all available evidence. We teach timeout for toddlers who bite and we role-play conflict resolution for school-age children who fight. When a long-term patient of mine was cruel to a smaller girl in her class, I accessed the American Academy of Pediatrics' recommendations for assessing and treating bullying. We strive to help our young patients become fulfilled, nonviolent members of their communities.
But when it comes to racial intolerance, we are often at a loss. We have no training in the complexities of discussing racism in the exam room, no evidence-based guidelines or practical tools at our disposal. In my seven years of training and 14 years of continuing medical education, I have never encountered a teaching module on addressing racial intolerance in my patients. As Lachelle Dawn Weeks, chair of Harvard Medical School's Social Justice Committee, states: "Medical education has fallen short in modeling the dialogue between health care providers and patients about patient-held biases." As a result, we remain silent.
We take an oath when we graduate medical school to care for all patients equally. Our oath prevents us from rejecting a patient based on his or her value system. But our oath does not compel us to look the other way.
As a profession, we must learn to address racism as well as we address other harmful behaviors. We must teach ourselves and our trainees how to establish an open, empathic dialogue when we encounter racial intolerance in real-time. We must not omit racism from the myriad of societal ills we address as we fulfill our oath to provide treatment to all.
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