Manichean medicine: patient-saint, patient-sinner

We are very pleased to post this wonderful piece of writing from “Anonymed”. He or she has good reasons for being anonymous which we won’t delve into. Sadly, 2023 is not a time of open and reasonable discussion in the western world, and particularly not in Canada.

I (Chris) will relate one personal story that relates directly to the essay.

A decade or so I saw a patient in the big ER where I worked at the time. He was unkempt, had shabby clothes and his teeth were obviously uncared for. In short, he was not a rich man. As I recall, he was there because of a boil.

When I came into the room, I introduced myself and asked my standard “What can I do for you today?”. His first comment was “Oh, I’m glad it’s you and not the Paki doctor”. (My colleague that night was from India).

To me, that word is like fingernails on a chalkboard. I hadn’t heard it in many years. It pierced my soul.

So I let him have it. I told him the word was racist. I told him my colleague was from India, not Pakistan (not that it would have mattered) and that he was an excellent physician - one who if the patient was luckier he would have gotten to see instead of me. I was flushed with anger.

He simply said “I’m sorry” and looked at his feet. He said little as I froze him up and lanced his boil. I left, and asked the nurse to go put a dressing on the “racist guy” in room 15.

When she came back, she said “he wanted to talk to you before he leaves”. This is a common thing for ER docs. Many patients have an extra question about follow up, a 2nd problem, or some other matter. So I pulled the curtain and said (extremely tersely) “I hear you have a question for me”.

“No doctor, I just wanted to apologize”, he said, still looking at his feet. He went on to explain that he was hearing impaired. He didn’t say, but I would guess he couldn’t afford hearing aids. The last time he had seen a doctor, it was someone with an accent who spoke quietly, and he couldn’t understand him. He was too embarrassed to admit he couldn’t understand and went away from that appointment not knowing anything about what was wrong with him or what to do. He had met me previously (I had forgotten) and knew that I A) spoke with a Cape Breton accent (which he understood) and B) was really loud (many can attest to that).

He finished by saying, with a tear in his eye that he didn’t know that “Paki” was a bad word, and that he would never use it again.

I have to say I felt like a complete heel. I had assumed the very worst of him. I suspect he grew up in a social milieu where the word was normal, and that he didn’t exactly get to hang around with people who knew better. I had berated and belittled a struggling, poor guy who meant no harm to anyone. I had punched down.

I assume there are some real overt racists out there, because everyone keeps saying there are. I’ve yet to meet one in person. So I suspect they are much rarer than the mainstream news and all the organizations I belong to tell me. Consider this: a few hundred people who could be described as “white nationalists” showed up in Charlottesville in 2017, out of a country of 340 million. The same weekend there was a convention for “Furries” (yeah, those people) in Las Vegas that attracted around 2500 people. Which of these groups is more of a threat to our social fabric?

Thanks so much to Anonymed for allowing us to share this with our readers. We hope that in the next few years, more physicians, healthcare providers, and patients will feel empowered to speak their minds on this issue. If so, we could then have a more balanced and productive discussion around issues of race in medicine. I hope this essay is one small piece in starting that conversation. Please pass it on.

Manichean dualism is the single worst idea people ever came up with -  this notion that you can divide humankind into the children of light and the children of darkness. - James Morrow

Time passes quickly in a revolution. One line is crossed, and then another, and another, until it is no longer the present that is surreal, but the past, and it feels almost childish to picture a time when things were different. In my darker moments, the last three years feel like one long list of transgressions against sanity - for society in general and medicine in particular. Despite serious concerns about postmodernism and its accoutrements, I honestly never thought I’d see the day when a (not insignificant) portion of the medical profession would delight in mobbing colleagues for thought crimes, lick its lips at the prospect of firing the lockdown and vaccine skeptics among us, declare racism a public health emergency of greater import than even COVID, advocate defunding the police as cities burned, or decide the best way to help a subset of confused children is to transform them into a parody of the opposite sex.

These are the dramatic, society-altering ones, but revolutions work in subtler ways, too. While everyone was busy embroidering #BlackLivesMatter into their scrub caps and issuing hostage statements about white privilege, the DEI machine also began imposing its oppressor-oppressee paradigm on an unlikely group - our patients. 

We already know from extensive media coverage that white doctors, especially the male ones, cause a lot of harm to minority patients - by not believing them, not treating their pain, not being culturally humble, not taking sufficient account of their “lived experience,” and all the rest. The patients on the receiving end of this mistreatment are the endowed victims of the system. But patients can be perpetrators, agents of that system, as well. 

In 2021, the College of Physicians and Surgeons of Ontario’s (CPSO) Dialogue featured an article with the title, “Treating Patient Bias.” Unsurprisingly, the piece was replete with anecdotes of patients saying rude and sometimes overtly racist things to minority physicians and learners, or refusing their care altogether. The identity of the offending patients wasn’t always clear, but it was understood, even when not stated explicitly, that they were talking about bigoted old whities. It was claimed that these unfortunate experiences lead to undue burnout and ultimately affect the supply of physicians in our already precariously staffed healthcare systems. So not only is racism keeping minority applicants out of medicine (as we are routinely told), but it's also forcing minority doctors out of the profession once they’re there. 

It is true that patients say and do crazy stuff all the time, and much of it would surely count as “microaggression” I have no doubt (what doesn’t though?). But what evidence is there that overt, bigoted mistreatment of medical students or staff is widespread, widely tolerated, or a unique feature of one group of people? Regarding the Canadian situation, the article quotes a study published in the journal Academic Medicine, which describes its methods as such: “An anonymous online survey of physicians and trainees who self-identify as Black (African/Afro-Canadian/African American/Afro-Caribbean) was administered in March and April 2018 through the Black Physicians’ Association of Ontario (BPAO) listserv. The survey was modeled on qualitative interview guides from American studies.” The results indicated that, “70 percent of respondents reported negative experiences based on their race…Black physicians were regularly mistaken for floor aides, housekeeping, personal support workers or nurses. They also expressed various experiences of being “othered”— repeatedly being asked where they were from, even when they were born in Canada. Some respondents to the survey wrote that they felt as though their competence was occasionally called into question with patients not on board with their plan until a White physician agreed with it.” 

I sincerely mean it when I say that genuine prejudice from patients should not be tolerated or normalized. However, it is this kind of qualitative, convenience-sampled study that gives DEI snakes carte blanche to sell their oils. A cursory reading of its findings would suggest there is an epidemic of racist abuse leveled at vulnerable colleagues. Maybe there is, but you’d be hard-pressed to discern that from a subjective questionnaire sent to the email list of the BPAO. And when every transgression, from actual bigotry to ignorance to a tone someone doesn’t like, is lumped into the same bin and justified as prejudice via pseudoscientific concepts like “implicit bias”, it not only empowers ideologues of the worst kind (who are always on hand to teach the bias away, for a fee) but also suggests that doctors should become moral and linguistic coaches to their patients. This is a very slippery slope to a place where the doctor-patient relationship becomes yet another front in the war to intersectionalize everything. 

Personally speaking, unless acutely psychotic, if a patient drops the n-word or some other such epithet, they’re getting an earful, just as they would if they leveled any verbal abuse at other patients or staff. But are we really going to pretend that in an interaction between a doctor and his or her patient, the powerful, (usually) wealthy physician “of colour” is the victim, while the sick and tired, rough around the edges, paycheck to paycheck white lady patient is the oppressor? Even if this were somehow the case, do we really think scorning a patient for being impolitic is the solution? The authors of the Dialogue piece contend that the purpose of addressing such behaviour is not to punish but to compassionately “educate” as well as learn what combination of factors made that person into the cancer they are. Forgive me, but I’ve heard enough of this kind of sanctimony to last me ten lifetimes and don’t trust it as far as I can hurl it. After all, how much education is needed before patients are speaking in an acceptable way? What if they don’t understand what a microaggression is? What if they still think, like the Neanderthals used to, that men and women are different? What if they think you’re just full of it?

To reiterate, I’m sure some such stories of mistreatment are true and lamentable (treat enough patients and you will see some shit), but the supply of such accounts has predictably proliferated with the demand for their wares. Regardless, medicine should not be in the hall-monitor business. I have little tolerance for bigotry, overt or otherwise, but I hope I’m not alone in thinking that we have lost our damn minds if we believe part of our job ought to involve “educating” fearful, anxious, suffering-soaked patients about the newest addition to the BIPOC children’s library.