Profession

How to handle a prejudiced patient

A column that answers questions on ethical issues in medical practice

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted March 3, 2008.

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When confronted with prejudiced patients, physicians may struggle to keep their emotions in check while treating those patients competently and with respect. Sometimes, it may be impossible to overcome a patient's intolerance.

Response

From the time of Hippocrates' Oath through today's ethical principles adopted by the American Medical Association, physicians have been expected to provide competent medical care with compassion and respect for human dignity and rights. Most physicians have managed to detach themselves from strong emotional reactions toward less-than-likeable patients and illnesses while maintaining a humane approach to their patients and their art.

But physicians are people too, and sometimes their emotions can be unleashed when faced with verbal or emotional abuse at the hands of patients who are judgmental. In the past, patient prejudice was directed to the race and gender of doctors. Today, a new form of patient prejudice is being more frequently encountered in clinics and hospitals by those thought to be Muslims or of Middle Eastern descent, especially after the attacks of Sept. 11 and the xenophobic media coverage. This discrimination affects physicians who look or sound different, have a different name or come from a different country.

Where once the competency and skills of a foreign physician might have been challenged, now there is an assumption that a doctor of a particular ethnicity has questionable ethics and morality. Given that these are hurtful and deeply personal comments, it is only natural for a physician to feel aggrieved and disturbed when his or her patient asks for a "doctor who can speak English" or a "doctor who is not a terrorist." Such remarks could be especially more traumatic if directed to a new resident or a veiled young woman intern.

Despite these harsh words, we, as physicians, have to remain courteous with all patients. Regardless of our strong emotions, we are expected to care dutifully for patients and treat them with respect. The sense of grief and injustice that we feel at hearing ignorant remarks should not lead to a reaction of anger or aggression.

But being passive in the face of outrageous comments might be interpreted by the speaker or others as acceptance of the remarks. Doctors should try to correct the patient who is making ignorant comments by using personality and, to some extent, their position of authority. While being careful not to intimidate patients, they can voice their disagreement and inform the patient that his or her remarks are inappropriate and offensive to staff and perhaps other patients. A firm yet polite statement will re-establish the physician's self-confidence and reaffirm his or her authoritative role.

Other doctors might use humor to defuse the tense situation. For example, an Arab-American colleague stated that he would respond to the request for an American physician with, "You're looking at him."

Doctors also have the duty to educate patients. If your patient were a smoker or an alcoholic, wouldn't you coach him or her on ways to quit? Should a doctor not make at least one attempt to correct the misconceptions of the accusing patient?

Still, it is not always easy to determine the right way to handle these types of patients. How to respond to racial or ethnic prejudice is not in any medical school curriculum, nor is there a standard policy in hospitals and health care facilities that can guide physician or staff response.

I think this is a failing of hospital administration. Isn't verbal and emotional abuse similar to sexual harassment? Shouldn't this behavior also have similar "zero tolerance" policies? If the U.S. Dept. of Labor's Occupational Safety and Health Administration recognizes "dealing with combative, disoriented, uncooperative patients" as a potential workplace violence hazard, shouldn't the AMA and other professional medical organizations advocate the implementation of such policies?

Some may ask if such approaches impede a patient's freedom of speech. I wonder if it is too extreme to delay treatment to an intolerant patient (in non-life-threatening situations) until he or she at least hears what the denigrated physician has to say.

What we must always keep in mind is that an integral part of the healing process is the mutual confidence the patient and physician have in each other. If this relationship is not established, then it will be difficult to treat a disease or medical condition successfully. With that in mind, if it is obvious that the physician cannot gain the patient's trust, then a last resort might be to comply with his or her wish for another physician.

Lastly, one should keep in mind what James Mannon, PhD, said in 1976 about the presence of the alcoholic, the emotionally disturbed and the mentally ill patient in the emergency department. Such patients, he said, represent an exercise in futility for emergency doctors and nurses, and one way for medical staff to cope with them is to define them as management problems rather than as medical cases to be diagnosed and treated. Success or failure with management problems is no longer based on medical criteria but upon the outcome of management activities.

Mouhanad Hammami, MD, pediatric researcher; faculty member, Wayne State University, Detroit; executive director of the National Arab American Medical Assn.

Response

In pre-9/11 America, most patients did not question the ethics or ability of the doctor who treated them. While they may have preferred doctors who looked like them, they generally put aside thoughts about the doctors' ethnic origin or religion in the interest of getting appropriate treatment.

Since 9/11, these assumptions have been replaced by suspicion, fear and prejudice. We have seen that when there is a major act of violence, it is attributed to a Muslim terrorist until it is proved otherwise. While the incidents of 9/11 did not change the behavior of doctors, the media and politically motivated scare tactics have helped fuel fear and uncertainty toward foreign and Muslim physicians in the general population. Often this can lead to prejudice, which can be exacerbated by the fact that many people haven't had an opportunity to interact with those who practice Islam or who are of Middle Eastern descent.

This type of intolerance is particularly challenging to physicians, because they must not only respond to the comments but also must face the fact that they are not their patients' first choice of doctor. Patients' rights already have been restricted when they are forced to subscribe to a certain health plan to pay for their medical services. The privilege of insurance coverage often comes at the expense of having the right to select a doctor they would most prefer. This less-than-ideal framework for medical care compromises the patient-physician relationship, which is the cornerstone of the clinical encounter, and fear and prejudice compound this challenge. If a patient does not have faith in a doctor, he or she is going to be less compliant and therefore less likely to recover in a timely manner.

In an emergency situation where the patient-doctor encounter is limited, a patient's opinions about a physician's ethnic origin may not play an important role. If it is a problem, I would gain the patient's consent for emergency treatment and inform him or her that alternate arrangements will be made as soon as he or she is stabilized. In nonurgent cases where the patient is ill-informed, may have had little education about a particular population, or had a bad experience in life that makes him or her apprehensive to be treated by a foreign doctor, it is worthwhile to try to educate the patient, explain your credentials and the fact that all physicians -- regardless of where they were educated -- must meet strict U.S. standards to practice in this country.

In general, the doctor should make every effort to listen carefully and to be polite and empathic. If a continuing relationship seems possible and patients are open to receiving care from a person they were initially unsure of, it is vital to put patients at ease during the first patient-physician encounter. The receptionist and nurse in the office can play an important role in helping to put the patient at ease and aware of what to expect.

In some instances it may be impossible to overcome deeply embedded feelings in a patient. If the patient believes he or she cannot work with the physician on a long-term basis, that patient can be directed to seek care elsewhere.

To me, the more interesting question is how do we respond to tomorrow's possible request for a doctor who is blond and has blue eyes? How accommodating must physicians be? The medical profession has no requirements for language, religion, gender or geographic place or origin of practice. We should not be shortsighted and ignore the service that foreign doctors are providing.

Ayaz Samadani, MD, family physician, Beaver Dam, Wis.; chair of Gov. Jim Doyle's appointed Public Health Council at the Dept. of Health and Family Services; president of the Wisconsin Medical Society Foundation

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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