What shall we do with the racist patient

I’m ethnically ambiguous, audibly foreign and don a white coat daily in the Midwest. I have a hard-earned expertise on the subject.

Racism is an integral part of daily European and American life, and likely many other lives I have yet to live. Not only are racist ideals ingrained in Western history and certain stubborn values, those transpire in the discourse of seemingly mundane topics such as fashion or IT; their sinister spirit permeates politics, education and medicine, which is where we collide.

While I would reluctantly give the American healthcare system a C+ for attempts at addressing racism at institutional level, thanks to the twisted notion of for-profit healthcare that “the customer is always right”, racism functions as a bidirectional valve for our filth as faulty humans. It actively splotches patient-provider interaction, leaving both parties stained with inexcusable hurt.

I’m a European with Ashkenazi, French and Romani genes in my DNA, and routinely get spoken to in Spanish or a tongue I can barely identify, and get asked if I’m Middle-Eastern/Afghani/Asian on a regular basis.

Growing up surrounded by people with blue or hazelnut eyes and light hair, I was subjected to racist bullying, called a “Gypsy” and threatened to be beat up by skinheads (it took me decades to even talk about it.)

With self-preserving instinct, I stopped sun-exposing and began whitening my skin, covering it with the palest makeup powders money could buy (thank you, Mac cosmetics.) I was craving to be called a Snow White, or at least anemic.

Halfway through my life and miles aways from those memories, I still don’t fully accept the way I look although I try to own it as much as my scarred soul lets me.

I’m not feeling sorry for myself.

I need time to grow.

Through the monochromatic American lens in which skin shade universally portends privilege or disadvantage regardless of class, disability, sexual preferences or gender, I’m perfectly fine and plague at me for complaining; although as an immigrant with a vagina, I still have to beg, steal and borrow to come anywhere near the opportunities offered to equally qualified American Americans (especially those endowed with a penis).

I’m always in the line behind them, waiting impatiently to bid my talent at a discounted price.

The cultural landscape of disadvantage or privilege is far more complex than both the conservative and liberal notions seem to allow (do I sound like J. D. Vance now?), and I consider myself an ignored part of the landscape, along with many highly qualified professionals who were not born in this country yet came here legally to hold jobs and pay taxes.

The wall for people like us may not be at the south border, but there certainly are countless invisible barriers we’re constantly forced to climb over with minimal — if any — support or at least acknowledgement from the greater society.

While I was working in New York, the realm of the medical profession was so diverse that my non-Americanness was far less prominent, although still catching up with me: I was never invited to social functions by American Americans, or to any educational or religious discourses if they had a say. Socially and professionally, playing the fourth fiddle was the best I could strive for.

I didn’t hear any outrageous remarks about my race or origin, the door simply didn’t open after I had knocked.

I kept striving, proving over and over again I can get the job done while witnessing non-immigrants get support and guidance to achieve the same goals I couldn’t even dream of.

Eventually, I was allowed through.

Yet the battle of ‘otherness’ was only just beginning.

Once I started working as a resident in the Bronx, I was shocked at the amount of inappropriate remarks towards providers of ethic heritage that went completely unchecked (boy, and were there many!). One would expect some guidelines on how to manage such situations given their prevalence, but there weren’t and still aren’t any. Any such notions were ignored, pretended not to exist.

One night in the ED in the Bronx, a bright attending of South Indian origin went to evaluate a somewhat belligerent Caribbean patient who presented with pain, sparing me the honor.

She returned shortly thereafter, visibly shaken: “She called me an Indian bitch,” the attending physician breathed out.

I’ve finally had it after all those months of subtle and not-so-subtle racial insults, and without a word I marched towards the patient: “Listen, if you insist on using a foul, offensive language towards the providers here, I will call the security and have you escorted out”, I roared a sheer lie, as technically, we aren’t allowed to escort anyone out unless they threaten the staff (I doubt she needed to know that.)

In fact, per administration, we are supposed to appease any and all ‘upset’ patients rather than challenge them, no matter how outrageous their behavior (a policy I strongly oppose, as there is a patently obvious difference between a scared patient who is miscommunicating his fears and certified assholes that abuse the staff.)

To my genuine surprise, the patient behaved for the rest of the night, confirming my long-held suspicion that racists will take their bravery only as far as we let them.

I was then carried to the Midwest by a swarm of bees. Here, I’m not even a part of the orchestra.

Very quickly I was forced to realize how glaringly un-American and exotic I seem, and accept being treated as such: I’m asked where I’m from at least every other day, feeling subtly on the defense, as if I need to justify my presence.

I used to say I’m from New York, as I‘ve lived there for almost a decade, but this wasn’t satisfying to the sharp Midwestern ears and was followed by the inevitable “where are you really from”? (A form of micro-aggression many non-White Americans are subjected to as well.)

Some people argue that patients are ‘just being friendly’, and I believe that to some extent, although being ID’ed like this is still uncomfortable. Moreover, the question isn’t always with friendly connotations:

An old, white male patient refused to talk to me because he “didn’t like my accent”. He then called our African American physician assistant a ‘cotton-picker’ in my absence.

Apparently, nobody said anything.

When I complained to a fellow resident of ethnic heritage that I was effectively kicked out of the encounter over being a foreigner, she said: “Do you know how often I’m told ‘how long have you been in the country, you speak such good English?’ Well, I’m from Kentucky…”

You win this one.

A few things are as ostracizing as being asked where you’re from in your own country (the reason I left mine.)

When a white male veteran recently presented to our clinic, a Midwest-born and raised American-Indian attending physician and I went in to see him together.

The first sentence out of the patient’s mouth: “Where are you from?”

Oddly, he isn’t asking me, as I haven’t even said a word to give him the ammunition.

He is asking the attending physician, a graduate of a top US medical school and a residency program.

I’m flabbergasted and mortified.

The attending maintains his perfectly professional demeanor and openly explains which state he grew up in, and that his family is originally from India.

“Oh, I’ve dealt with your race before,” says the patient and my pupils become mydriatic.

He’s not finished.

“Are you a Cherokee Indian?”

This time he’s asking me.

I look over my shoulder to make sure the spirit of Cuhtahlatah isn’t hovering behind my back.

That’s a first; no, hang on, I was asked this once before actually, for equally wrong reasons.

“What makes you think that,” I ask with insincere sweetness.

“Oh, you know, your hair, your style…”

As I’m about to scorch him with a sarcasm along the lines of ‘I thought you must be thinking we are from the same tribe,’ the attending physician intervenes, politely providing my credentials (he must have seen the lighting lashing from my eyes.)

This kind of (micro)aggression is inexcusable in my playbook: I’ve been a patient before, treated by a variety of physicians and never in my life did I ask anyone where they’re from or their tribe.

When we finally leave the room, I — still quite upset — let go and ask the attending: “what the hell was that?”

He, forever a better person than I’ll ever be, says:

“Oh, him commenting on my race? He was just being friendly, he was trying to connect”.

There isn’t a parallel universe in which I accept this as the truth, but I’m disarmed.

The incident is so upsetting that I end-up talking about it with a nurse two days later. She scoffs and adds: “You don’t want to know how often it happens when we call a patient that a doctor so-and-so will be covering a procedure, they say ‘well where is HE from!’…”.

“How often does it happen?”

“More often than it should”.

“What do you say to them?”

“That he’s American,” she shrugs her shoulders.

Well, I’m not.

I don’t question the need to address racism on the part of providers and the healthcare system as a whole, but systemic issues in healthcare should not serve as excuses for bigoted comments by any patients towards providers. I’m a doctor, not a robotic saint, and I have no reason to pretend that bigotry is somehow acceptable just because someone is unwell (there’s no ICD-10 for racism.)

Moreover, documented evidence shows the lasting negative impact of racist expression toward providers. https://journalofethics.ama-assn.org/article/how-should-organizations-respond-racism-against-health-care-workers/2019-06

The white coat is not a sufficient shield to protect me or my colleagues from abuse and personal attacks in case we don’t fit someone’s mold about who should be allowed to practice medicine; the identical kind of irrevocable harm I was trying to leave behind when I left where I’m “really from”.

It seems even more absurd in the current era of a non-zero chance of being intubated by a pathologist (can’t guarantee he is an American.)

So what shall we do with the racist patient? Per administration, pretend he isn’t there along with the harm he is causing. From my perspective, it is unethical to let harmful expressions of bias go unchecked, and rectification requires a wider discourse and defined tools for providers to clarify what’s acceptable without compromising patient care.

Sadly, I’m not holding my breath.

Also, as a personal favor, please stop asking your doctors where they’re “really from.”