Meeting Mrs Smith "I want to see the doctor," the patient gasped, staring at my face. I thought she'd mistaken me for a nurse. It happened every day to female doctors, even though in the United Kingdom, where I was working, nurses wore distinct uniforms and doctors dressed smartly in their own clothes. "I am the doctor," I said. "I don't like your kind. I want a white doctor. A man." My cheeks burned. I pivoted on my heels and walked out, feeling a cool relief that I could close the door on Mrs Smith, that her racism and sexism could be contained inside a room and not let loose on the ward like a bad smell. I should have called a superior to ask for help—maybe my consultant, a pragmatic Bengali man with expertise in emergency medicine and intensive care. I should have bleeped the on-call registrar, a no-nonsense Indian woman who might have been flustered but whom I imagined would find a brilliant solution. It was 2010, and I was an intern in an East London hospital, where a significant minority of doctors was not white. But I felt too much shame. Interns weren't supposed to complain. And there wasn't enough time. It was a busy evening, with too few doctors and a steady stream of patients who needed to be clerked. I had troponin levels to check and lines to replace, and Mrs Smith, an older white woman admitted with worsening chronic obstructive pulmonary disease, needed her arterial blood gas tested. Besides, this had happened before. Not a blatant request for a white doctor, but sly digs at my competence on the basis of my name, the color of my skin, or my dresses. "Speak slowly," one older patient had said as I pushed back the curtains. "I don't understand you people." Then there were the racist and sexist insults cloaked in so-called compliments. "You're too pretty to be a doctor. Get me someone who went to went to medical school, not beauty school." Or, "Your English is wonderful, dear. How long did it take you to learn to speak like that?" And, "You are a clever girl, aren't you? In which country did you go to medical school?" I had graduated from medical school at the University of Cambridge 9 months before I met Mrs Smith. It was at Cambridge that a Sri Lankan doctor with a six-syllable last name taught me how to slowly angle a fine-gauge needle through the delicate skin of a patient's inner wrist to draw arterial blood. Instead of thrusting the more commonly used and wider 23-gauge needle, I could take an arterial blood gas measurement while eliciting the slightest of winces from my patients. But Mrs Smith wanted a white doctor, and a man. And I simply replied, "OK," before exiting the room. There were no guidelines on how to deal with racist, sexist patients. It had never been covered in medical school or during intern orientation. I knew where the crash carts lived on each ward; I knew how to call hospital security. No one had told me what to do if my help was refused because I was brown and a woman. Seeking Guidance That's not unusual. Although many doctors face discrimination—a 2015 study of Stanford University pediatric residents found that 15% experienced or witnessed discrimination from a patient or a patient's family—there are no clear guidelines on how to respond. The American Medical Association's code of medical ethics does not specifically address racist, sexist patients demanding white, male doctors. Instead, the code speaks broadly to "disruptive behavior by patients." That's shortsighted. About 280,000 doctors in the United States are international medical graduates, according to the American Medical Association. That's 1 in 4 doctors. After President Trump's first iteration of the Muslim ban in January, I interviewed some of those affected by the new policy for articles that appeared in Scientific American and the Dallas Morning News. Racist interactions were part of being a doctor in the West, they told me. Just another professional hazard, like needle-stick injuries and deranged sleep cycles. Racist patients and the shame and degradation they incited were not to be discussed. You shrug off the ignominy of being referred to as "you people" during the ward round because medical school teaches and residency reaffirms that the patient—even the racist one—always comes first. In a 2016 New England Journal of Medicine article titled "Dealing with Racist Patients," the authors wrote that "competent patients have the right to refuse medical care..." and "employees of health care institutions have the right to a workplace free from discrimination based on race, color, religion, sex, and national origin...." The authors offer a framework for dealing with such patients as Mrs Smith, which begins with determining whether the patient is stable or unstable and assessing their capacity to make a decision. For me, that meant evaluating Mrs Smith's pallor, respiratory rate, oxygen saturation, and use of accessory muscles, among other things, as she told me she would not be touched by a brown woman. An Uncertain Path Forward In the past year, I've watched as that kind of anti-woman, anti-foreigner, anti-Muslim vitriol has flourished. It's a platform exploited by the man who holds the highest office in the land, a man who has emboldened racists to spew their racism. On the day the presidential election results were announced in November, I was teaching epidemiology to a class of mostly premed students at the University of Texas at Dallas. Some of my students cried so hard, fearing for their safety and dignity, that they had to be excused from class. They will meet many Mrs Smiths. Patients whose blood fizzes with carbon dioxide, their shoulders hunched, hands gripped around the edge of an examination table, intercostal muscles retracted against the strain of stiff lungs. Patients who will use what precious oxygen floats in those rigid lungs to say, "I don't like your kind. I want a white doctor. A man." And we brown women will care for them as best we can, because that is what we do. That night in 2010 when I was an intern, I actually walked through half a dozen wards looking for a white doctor for Mrs Smith. It was a futile pursuit in an East London hospital. Eventually, I found a young man, a fellow intern who was Indian, and I briefed him on the interaction and the need for an arterial blood gas measurement. He followed me back to the ward, where I had assembled the apparatus needed for the test. He picked a thicker needle than the one I would have used and entered Mrs Smith's room. I heard some mumbled talking and then a groan, presumably at the point where his needle penetrated an artery in Mrs Smith's wrist. Then my bleeper buzzed. A patient was in cardiac arrest and I ran through the hospital, shoving my shame and my relief into blue latex gloves, and never mentioning again what had happened. Source
