Tuesday, March 15, 2016

Rascism and the duty to accomodate

A couple of weeks ago a patient refused to let one of my colleagues give her an anaesthetic because of his race.  What race is not important although you can probably guess.  The surgeon was very much less than supportive of his anesthetic colleague and the case went ahead after my colleague switched rooms with somebody of an acceptable race.  One of the OR nurses was disgusted and refused to work on the patient and she swapped out of the room as well.

Of course when pressed, the patient denied being racist; she said she just wanted to know what his qualifications were.

In case she reads this blog, my colleague was born in Canada, attended medical school in Canada, did a Canadian residency and has a Canadian fellowship.

Admin got involved and we got a meeting with the VP of Ethics and Spirituality (yes such a position actually exists).

It was a good meeting.  He started out by bringing in the CMPA's statement on you to deal with requests based on race.  It is the usual bland unhelpful document that the CMPA puts out.  Essentially racism is bad but try to accommodate the patient anyway. He then brought out the hospital's policy which essentially said the same.  Historically this situation raised its ugly head when women from a certain religion refused to have male doctors look after them in Obstetrics (presumably male nurses too although these are rare in OB).  This is of course a problem because while the woman can go to female GP or OB; doctors do share call and take time off plus male residents also rotate through OB and are expected to deliver patient care.  The solution was to meet with the local leaders of said religion and also to consult said religion's holy book, which aside from some vague statements about modesty was fairly tacit about whether women could or could not have physicians of a different gender.

Anyway periodically when up in the labour floor I will see a sign on the door stating no male staff.  I have been involved in 2 incidents personally.  The first was when I was doing a booked C section.  The usual practice at our hospital is that we see the patient for the first time in the OR, usually sitting up waiting for their spinal.  This is not ideal, but it is how we do things and nobody is stopping anybody from finding the patient in their room pre-op.  I walked around to face the patient and was struck by her facial expression.  When seeing patients pre-op you can see a variety of facial expressions, nervousness, fear, hope, happiness.  What I saw on this patient was hatred.  "She doesn't want a male doctor," said one of the nurses, "but we told her she had to have one."  L+D nurses have never heard of patient autonomy.  I mentioned that had they called me earlier, I probably could have swapped with one of the female members of my department.  Not that I should have to of course and the case went uneventfully.  About a month later I was finishing a C section when the nurse stuck her head in the door and told me I had a retained placenta next door for a GA as soon as I was finished.  The patient when I arrived in the room was quite upset at my presence (this doesn't happen normally) but again the nurses told her she was bleeding to death and I was the only available person.

This lead to a discussion.  During the day you can usually find another person if the patient is uncomfortable with you for any reason.  After hours is different.  Somebody raised the issue of what happens when the first and second call are both of the same sex.  Do you phone around and try to find a staff member of the appropriate sex at 0200?  Even if the second call is of the right sex, they are usually home; do you call them in. Would you come if you got called under these circumstances?

What we are discussing above is however selecting doctors by sex even when it is based on cultural practices.  Most of us are willing to condone selecting doctors by sex, lots of people do it based on personal preference or because of bad experiences, not necessarily medical, with the other sex.  But is selecting your doctor on the basis of his sex just the thin edge of a wedge where the thick end is selecting your doctor by his race.

This already happens on an informal basis.  Despite what you may have heard in the health care debates, patients in Canada get to chose both their primary care doctors and subject to availability their specialists.  I suspect a whole lot of choice may be based on the doctor's sex, skin colour or accent.  It is just never out in the open.

Anaesthesia is a little different.  Patients are assigned to an anaesthesiologist based on whatever system the hospital uses to assign them.  We do however allow again subject to availability patients to occasionally request anaesthesiologists.  When I first started out 25 years ago I noticed that most of the patient requests were vascular patients and it was the same 3, more senior, anaesthesiologists and I realized that it probably wasn't the patients who made the request but rather the surgeons who were concerned that a younger anaesthesiologist was going to cancel the patient many of whom had quite severe cardiac or pulmonary disease.  I also realized when I became department head is that a certain number of requests are not because they want a certain anaesthesiologist but rather because they don't want a certain anaesthesiologist and you can't put that on a booking form.  So I wonder how many patients just told their surgeon they wanted or didn't want a white/yellow/brown/black anesthesiologist and the surgeon just requested someone of an acceptable colour.

After our spirituality person gave his spiel my colleague who had been affected put in his two bits.  He has, as he said, been the race he is all his life.  He states he notices about once a week that a patient is very uncomfortable with him and he has learned to deal with it.  We have a lot more visible minorities in medicine now and while we can pat ourselves on back at their success, we have no idea of what they face on a daily basis in their work and I think what it would like for me to face a patient like the lady above who wanted a female anaesthesiologist, once a week. 

Probably if you surveyed our department, most people felt the patient should have been cancelled and told that she was no longer welcome at our hospital.  She had come in for a total joint replacement and as I constantly remind my ortho friends, nobody has ever died from osteoarthritis.  One person pointed out we are not doing her or anybody a favour by not allowing her to see the consequences of her actions and attitudes.

I continue to be disappointed in the 21st century and it is not because we don't have flying cars or colonies on Mars.

1 comment:

ZMD said...

Well said. Here in California we are have an extremely diverse population so race selection by patients isn't as much of an issue. Or maybe I'm just the wrong race to notice. However I have worked in the Midwest and I've seen patients reject a physician because he was the wrong skin pigment though like your experience she denied being racist.