Dear Director: Occasionally I have a patient refuse to let me care for them because they don’t like my gender/skin color/nationality, and they want another doctor. Should I give in to them and get a colleague or tell them it’s me or the highway?
I was on my last call night at the trauma center during residency when an intoxicated, multi-trauma, motorcyclist came into our trauma bay. He was screaming profanities and refusing to be cared for by our African-American trauma attending. Although the patient may have been a racist, he was not competent at that point to refuse care. Dr. C, our attending, calmly told him that he was the attending in charge and that if the patient was going to live, he (Dr. C) was the one to make it happen. The patient continued to call Dr. C. names, but ultimately our work up and care proceeded, he was intubated, and his life was saved.
There are numerous studies demonstrating that medical professionals face discrimination from patients, and if you’ve worked in the ED long enough, you’ve seen patients who don’t like people because of the color of their skin or the place where they worship, among other reasons. You may have read how Esther Choo, MD brought national attention to racism in medicine in August via a Twitter thread sharing her experience—and response—to prejudice on the job and wondered, “What would I do?” or “Where does my hospital stand on patient preference based on race, gender, etc.?”
It seems unfair that patients can refuse our care, make nasty and inappropriate remarks, and yet we are still supposed to be respectful of them, offering care and accommodating their wishes. No one said taking the “high road” was easy.
I happen to be a white male with a Jewish last name. There are patients who aren’t Jewish who ask me if I am and say they like having a Jewish doctor because they think they’re better (It’s easy to forget that prejudice can work in both directions). These comments far outnumber the neo-Nazis I’ve taken care of.
Policy
There are few, if any, policies from physician organizations about how to handle the racist patient. Since, I am not an attorney, an ethicist, or a philosopher, but rather an ED director who lives in the real world, I hope to be able to offer a practical approach.
We have a hard job, and fixing racism has never been in our job descriptions. Most of us go into each shift with a desire to take care of patients and do a good job. I also do not believe that if someone hates a certain group of people (gender, religion, sexual orientation, etc.) and doesn’t want them as their doc, saving their life isn’t likely to change their opinion of that group. Why should we make our job harder just to prove a point that we can take care of them if there is another option?
On the other hand, as a director and administrator who interacts with the c-suite regularly, I understand that patient experience is being measured every shift and is important. While I will address the patient who refuses care from one provider, it’s important to note that there are many shades of prejudice, and many bigots do not overtly display their feelings, yet they may be unsatisfied with your care no matter how exemplary. They expect bad outcomes, and they may be more likely to sue regardless of actual harm done. Start by investigating your hospital’s policy and perhaps consulting Human Resources.
Ethical Issues
There are other people who for religious reasons prefer a same-sex physician. I work in the DC metro area. Our patient population is pretty diverse. It’s not uncommon for me to have a Muslim woman with miscarriage-like symptoms and she or her husband request a female physician. That seems reasonable to me, and I try to honor the request whenever possible. If we have a female provider on, I’ll ask her to take the patient, and I’ll just take the next one. It happens often enough that it doesn’t raise any eyebrows. But if I’m the only doc or we only have males working, I let the patient/family know. Typically, it’s not a problem, though I have had to explain that a female nurse can’t do the pelvic exam. Generally, I’m able to do most of the history and exam, they defer the pelvic exam, we get an ultrasound if necessary, and have a diagnosis. Some minority groups may have some mistrust of the system or have been victims of discrimination, so they ask for a particular type of physician. This is different than bigotry, and although I can’t recall having a case like this, I can see it happening and it being appropriate to find a concordant physician, if possible.
Legal Issues
There are a variety of legal issues involved when patients refuse care from a physician in an ED. We are required by EMTALA to provide a medical screening exam, stabilization, and transfer if necessary. Patients also consent for treatment, and they can refuse treatment by a physician if they’re competent to do so. In addition to these laws, Title VII of the 1964 Civil Rights Act protects employees from a workplace that discriminates based on race, color, religion, sex, and national origin. Nurses have successfully sued employers who required employees to accommodate requests that show bigotry or discrimination. These legal issues may collide when a patient refuses care by a physician because of prejudice.
If the patient isn’t competent, then we need to take care of them. Likewise, if the patient is unstable, we also need to take care of them. Whether hypoxic or hypotensive, etc., we can’t let someone die while we look for another doctor.
Of course, we will continue to see competent, stable patients who are just bigoted. Still, in serving them, I think there are only so many hoops we should jump through to get them a doctor of their choosing. After all, this is not a private practice but an emergency department, and not every ED is staffed with multiple providers. We are also entitled to a workplace free of harassment under Title VII.
Clinical Issues
I’ve taken care of numerous intoxicated patients who have called me names or wanted another doctor because of my last name, but patients with altered mental status may be intoxicated, head injured, or delirious secondary to a medical condition and typically are not competent to refuse care. Some of these patients have sobered up and been apologetic. Others had no recollection of their inappropriate behavior, while a small subset remained confrontational when they sobered up.
I’ve taken care of patients with Swastika tattoos who strangely enough didn’t request another physician. I asked a friend who’s a female, African-American what she would do if a patient requests another provider, and her response was that she’d happily get them another doc if one were available. She told me her job was hard enough; the last thing she needed was a patient not trusting her or being angry with her because of the color of her skin. Ultimately, if the workload and the scenario allow it, we should just try to find another provider to care for the patient. In situations where there is no alternative, the patient should be presented with the choice to continue care or not. This may involve some negotiation, and there may need to be a discussion based on acceptable behavior while in the ED. If the patient is stable and there’s another provider who fits their needs coming in shortly, maybe that will work. But I hate to think that someone would rather risk dying than being cared for by someone with different skin color or religion than their own. At the end of the day, we need to remain professional and realize the problem is with the patient, not with us.
Playing Favorites
Every ED I’ve worked in has had at least a couple of patients request a physicians of a particular gender for their GU or rectal complaint and after you see the patient, you realize the exam was just part of a fetish. After a couple visits, these are usually well documented in the EMR, and we stop letting the patient choose the sex of the provider.
Where I work, the opioid dependent patient looking for doctors who haven’t already told them no is more common than those avoiding demographic groups. I don’t think this qualifies as a legitimate reason to have a new physician assigned, and most doctors I’ve worked with don’t honor these types of requests. We shouldn’t turf the difficult patients to a colleague just because they’re difficult, and the patient is asking for someone else.
A patient’s family member may also approach you asking you to take over the care because they’re dissatisfied with the current emergency physician. In my experience, these are typically nursing home patients with lots of real illness and end up in the ED on a regular basis. Maybe the family remembers you from another visit. From my point of view, I also think some families may be under the mistaken belief that being cared for by the chair gets you better care than the full-time clinician actually caring for them. I’ll typically check in with the doc seeing the patient and try to see what’s going on. I’ll let them know the family may be dissatisfied and approached me. My usual practice is not to take over the case but rather to reassure the family that they’re in good hands. Typically, these are difficult-to-satisfy families who would be unhappy with whoever took care of the patient.
Conclusions
Based on the increasing diversity of the country and events that continue to unfold regarding race relations, I have no doubt that we’ll see more, not less, of ED patients requesting care by other physicians than the one who initially goes into the room. So, our job is hard, and it’s not likely to get any easier anytime soon.
We have an obligation to provide care for all patients who seek it. If the situation permits, and the clinical scenario is appropriate, we should try to accommodate patients who have specific requests regarding their provider. However, for the bigoted, competent, stable patient, if there is no other provider, at some point, the patient needs to decide if they want care or not in the ED. We also need to work with our hospital administrators so they see the prejudice we face and hopefully publicly support the medical team. Ideally, our medical societies will also publish policy statements on how physicians should handle racist patients.
