Opinion
A PIECE OF MY MIND Meghan Lane-Fall, MD, MSHP Departments of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Corresponding Author: Meghan Lane-Fall, MD, MSHP (meghan.lane-fall @uphs.upenn.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Accommodating Bigotry Gregory McGriff is an Ivy league–trained internist who was once dismissed from a patient’s room because McGriff is black. National Public Radio aired the physician’s story in May 2013 as part of its Race Card project.1 McGriff went on to relate a different incident in which a patient complained that he was “uppity,” having used terminology that the patient did not understand. McGriff’s narrative brought to mind an occasion when I cared for an elderly member of the Ku Klux Klan. The man found himself in our surgical intensive care unit in Philadelphia, cared for by me, a black physician, along with a rainbow of Jewish, Latino, and Asian health professionals. His endotracheal tube prevented him from commenting on his United Nations health care team, but he did look somewhat wideeyed whenever we entered his room. I have personally never been dismissed by a patient or family member, but I have received befuddled looks when I introduce myself as a physician. Of course, I cannot definitively tie this puzzlement to race, but having been asked on numerous occasions where I undertook training, I posit that there must be something about my appearance or demeanor that makes people question my credentials. (I should mention that these incidents are vastly outnumbered by the times that I introduce myself and receive a warm smile or even a “Right on, Sister.”) Despite the United States’ inexorable march toward racial, ethnic, and gender equality, it is clear that prejudice persists. What I find difficult to reconcile is how to deal with patient prejudices in a health care system with a growing emphasis on patient-centered care. Does a patient have the right to request or to deny a clinician of a certain race, ethnicity, gender, religion, or sexual orientation? Physician-patient race concordance has emerged in the disparities literature as a factor in differential health outcomes. When patients and physicians share race, visits tend to be longer and patient satisfaction is higher,2 bolstering the argument that patient preferences (assuming they prefer concordance) should be respected. Reflecting on my own experience, I can understand why race concordance might be appealing. While I would never refuse a health professional because of his or her demographic characteristics, I immediately feel more at ease with clinicians sharing my cultural background. It seems that there is so much that I don’t have to explain, justifications that I don’t have to make. We regularly encounter “affirmative preference”—a patient stating that he or she would like a provider with certain characteristics—in the form of female patients requesting female clinicians. Although the question often goes unasked, we may suspect that factors such as religious beliefs or a history of sexual violence are at play. The specter of these possibilities le-
gitimizes gender requests irrespective of their origins, and we happily accommodate them, especially in matters of sexual or reproductive health. While there may be tangible benefits to accommodating a patient's affirmative preference with respect to clinician race, gender, or other characteristics, the reciprocal question is perhaps more troublesome: Should a patient’s refusal of care by clinicians with “objectionable” attributes be similarly accommodated? This question gets a humorous treatment in the 2012 movie The Best Exotic Marigold Hotel. In the film, Maggie Smith’s character finds herself experiencing a prolonged wait in a UK emergency department because she doesn’t want to be treated by “brown doctors.” She is gleefully overlooked by physicians and nurses who seem to want to teach her a lesson by parking her in a hallway and ignoring her pleas for tea. Her “negative preference” is evidently based on prejudicial attitudes about the inferiority of nonwhite physicians, and its accommodation is therefore more difficult to stomach. Though the clinicians’ response is perhaps understandable, we should challenge ourselves to think about why we accept some preferences and not others. How are we to respond to patient preferences for clinician race? The law offers some guidance here. Fordham law professor Kimani Paul-Emile explored the practice of accommodating patients’ preferences for health professional race in her treatise “Patients’ Racial Preferences and the Medical Culture of Accommodation.”3 The fundamental question she considers is whether hospitals and physicians should accommodate racial preferences given antidiscrimination statutes. Title VII of the Civil Rights Act of 1964 bars all employers from discriminating with respect to employment conditions or terms on the basis of race, color, religion, sex, or national origin.3 Reading “discrimination” in its broadest sense, I interpret Title VII’s language to mean that hospitals and health care professionals should not make provider-patient assignments that account for the race of either. Title VII formed the basis of a 2010 lawsuit in which a black certified nursing assistant (CNA) sued the nursing home employing her for acceding to the wishes of a resident who preferred no black CNAs.3,4 The Seventh Circuit Court of Appeals found that Title VII prohibited the nursing home from accommodating the resident’s request.3 More recently, black employees at a Michigan nursing home were told that they could not care for a certain resident who claimed abuse by a black employee (he later recanted),5 and four nurses sued Hurley Hospital in Flint, Michigan, for accommodating a white supremacist patient’s demand that no black nurses touch his newborn child4; Title VII’s provisions are likely to apply in these cases as well. Despite the provisions of Title VII, there are reasons to believe that medicine is different.3 The Ameri-
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Opinion A Piece of My Mind
can Medical Association’s Code of Medical Ethics holds that patients have the right to choose their medical providers.6 The intimate nature of the patient-physician relationship requires trust and engagement. It is easy to understand how the therapeutic relationship might be undermined if a patient is cared for by an unwanted health professional. In an illustrative case, a hospital ethicist in Hawaii recounts the tale of a Korean gentleman who refused life-saving therapy but still wished to remain full code.7 In reconciling this apparent contradiction, the ethicist found that the patient worried that his Japanese physicians were in fact trying to kill him. Only after his care was transferred to non-Japanese physicians did the patient accept treatment and recover from his illness. In another case, a surgeon, fearing that the patient would forego a necessary procedure, acquiesced to a patient’s husband’s request that no black men enter the operating room during his wife’s surgery.8 Physicians have an ethical duty to ensure that patients receive needed care. In the surgeon’s story above, the patient had actually been referred to him by a different surgeon who would not accommodate the request to exclude black men from the operating theater.8 The referring surgeon appropriately fulfilled his duty by helping the patient find a surgeon who would accept her conditions. In health care settings with many clinicians, considering the accommodation question is largely academic; it is a trivial matter to refer the patient elsewhere.
However, when clinicians are scarce as in rural settings or in emergencies, a patient’s affirmative or negative preference may be at odds with his or her clinical interests. If a trauma patient requiring emergency surgery presents to my hospital at 3 AM, I may be the only supervising anesthesiologist present. If I am on call with our black trauma surgeon, and the patient requests no black health care professionals, what course shall we take? Should that patient not undergo surgery? Ethics consultations can be helpful in such situations when time allows, but ultimately, competent patients must be allowed to decide who cares for them and how. Just as we would accept a Jehovah’s Witness’ life-threatening refusal of blood transfusion, so must we respect a patient’s desire for certain care professionals. Faced with this decision, I would comply with the patient’s wishes. To do otherwise would risk committing battery, the act of intentional nonconsensual offensive contact.9 I can only hope that the prospect of irrevocable harm would force an urgent reconsideration of our patient’s prejudices. Does patient-centered care, then, justify tolerating bigotry? In my opinion, yes. I cannot countenance bigotry and other forms of prejudice, but my discomfort with a patient’s beliefs does not trump their right to specify the conditions of their care. It is my hope that by affording all patients with the respect that was so often denied to my forebears, the questions I have considered here will eventually become irrelevant to the practice of medicine.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
4. Karoub J. Some patients won’t see nurses of different race. http://bigstory.ap.org/article/some -patients-wont-see-nurses-different-race. Accessed October 17, 2013.
1. Norris M. For a black doctor, building trust by slowing down. http://www.npr.org/2013/05/01 /178442772/for-a-black-doctor-building-trust-by -slowing-down. Accessed October 17, 2013.
5. Newsroom WNEM. Nurses told not to touch white patient. http://www.wnem.com/story /22911660/nurses-told-not-to-touch-white -patient. Accessed October 17, 2013.
2. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915.
6. American Medical Association. Opinion 9.06. Free choice. Code of Medical Ethics. 2012. http://www.ama-assn.org/ama/pub/physician -resources/medical-ethics/code-medical-ethics /opinion906.page.
7. Kipnis K. Quality care and the wounds of diversity. In: Mappes T, DeGrazia D, eds. Biomedical Ethics. 6th ed. Boston, MA: McGraw-Hill; 2006. 8. Foubister V. Requests by patients can put doctors in ethical bind. Am Med News. 2001;22(January):•. http://business .highbeam.com/137033/article-1G1-70395591 /requests-patients-can-put-doctors-ethical-bind. 9. Legal Information Institute. Battery. August 19, 2010. http://www.law.cornell.edu/wex/battery. Accessed October 17, 2013.
3. Paul-Emile K. Patients' racial preferences and the medical culture of accommodation. UCLA Law Rev. 2012;60(2):462-504.
140
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Copyright 2014 American Medical Association. All rights reserved.
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A PIECE OF MY MIND Meghan Lane-Fall, MD, MSHP Departments of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Corresponding Author: Meghan Lane-Fall, MD, MSHP (meghan.lane-fall @uphs.upenn.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Accommodating Bigotry Gregory McGriff is an Ivy league–trained internist who was once dismissed from a patient’s room because McGriff is black. National Public Radio aired the physician’s story in May 2013 as part of its Race Card project.1 McGriff went on to relate a different incident in which a patient complained that he was “uppity,” having used terminology that the patient did not understand. McGriff’s narrative brought to mind an occasion when I cared for an elderly member of the Ku Klux Klan. The man found himself in our surgical intensive care unit in Philadelphia, cared for by me, a black physician, along with a rainbow of Jewish, Latino, and Asian health professionals. His endotracheal tube prevented him from commenting on his United Nations health care team, but he did look somewhat wideeyed whenever we entered his room. I have personally never been dismissed by a patient or family member, but I have received befuddled looks when I introduce myself as a physician. Of course, I cannot definitively tie this puzzlement to race, but having been asked on numerous occasions where I undertook training, I posit that there must be something about my appearance or demeanor that makes people question my credentials. (I should mention that these incidents are vastly outnumbered by the times that I introduce myself and receive a warm smile or even a “Right on, Sister.”) Despite the United States’ inexorable march toward racial, ethnic, and gender equality, it is clear that prejudice persists. What I find difficult to reconcile is how to deal with patient prejudices in a health care system with a growing emphasis on patient-centered care. Does a patient have the right to request or to deny a clinician of a certain race, ethnicity, gender, religion, or sexual orientation? Physician-patient race concordance has emerged in the disparities literature as a factor in differential health outcomes. When patients and physicians share race, visits tend to be longer and patient satisfaction is higher,2 bolstering the argument that patient preferences (assuming they prefer concordance) should be respected. Reflecting on my own experience, I can understand why race concordance might be appealing. While I would never refuse a health professional because of his or her demographic characteristics, I immediately feel more at ease with clinicians sharing my cultural background. It seems that there is so much that I don’t have to explain, justifications that I don’t have to make. We regularly encounter “affirmative preference”—a patient stating that he or she would like a provider with certain characteristics—in the form of female patients requesting female clinicians. Although the question often goes unasked, we may suspect that factors such as religious beliefs or a history of sexual violence are at play. The specter of these possibilities le-
gitimizes gender requests irrespective of their origins, and we happily accommodate them, especially in matters of sexual or reproductive health. While there may be tangible benefits to accommodating a patient's affirmative preference with respect to clinician race, gender, or other characteristics, the reciprocal question is perhaps more troublesome: Should a patient’s refusal of care by clinicians with “objectionable” attributes be similarly accommodated? This question gets a humorous treatment in the 2012 movie The Best Exotic Marigold Hotel. In the film, Maggie Smith’s character finds herself experiencing a prolonged wait in a UK emergency department because she doesn’t want to be treated by “brown doctors.” She is gleefully overlooked by physicians and nurses who seem to want to teach her a lesson by parking her in a hallway and ignoring her pleas for tea. Her “negative preference” is evidently based on prejudicial attitudes about the inferiority of nonwhite physicians, and its accommodation is therefore more difficult to stomach. Though the clinicians’ response is perhaps understandable, we should challenge ourselves to think about why we accept some preferences and not others. How are we to respond to patient preferences for clinician race? The law offers some guidance here. Fordham law professor Kimani Paul-Emile explored the practice of accommodating patients’ preferences for health professional race in her treatise “Patients’ Racial Preferences and the Medical Culture of Accommodation.”3 The fundamental question she considers is whether hospitals and physicians should accommodate racial preferences given antidiscrimination statutes. Title VII of the Civil Rights Act of 1964 bars all employers from discriminating with respect to employment conditions or terms on the basis of race, color, religion, sex, or national origin.3 Reading “discrimination” in its broadest sense, I interpret Title VII’s language to mean that hospitals and health care professionals should not make provider-patient assignments that account for the race of either. Title VII formed the basis of a 2010 lawsuit in which a black certified nursing assistant (CNA) sued the nursing home employing her for acceding to the wishes of a resident who preferred no black CNAs.3,4 The Seventh Circuit Court of Appeals found that Title VII prohibited the nursing home from accommodating the resident’s request.3 More recently, black employees at a Michigan nursing home were told that they could not care for a certain resident who claimed abuse by a black employee (he later recanted),5 and four nurses sued Hurley Hospital in Flint, Michigan, for accommodating a white supremacist patient’s demand that no black nurses touch his newborn child4; Title VII’s provisions are likely to apply in these cases as well. Despite the provisions of Title VII, there are reasons to believe that medicine is different.3 The Ameri-
jama.com
JAMA January 8, 2014 Volume 311, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Ndsu Library Periodicals User on 06/05/2015
139
Opinion A Piece of My Mind
can Medical Association’s Code of Medical Ethics holds that patients have the right to choose their medical providers.6 The intimate nature of the patient-physician relationship requires trust and engagement. It is easy to understand how the therapeutic relationship might be undermined if a patient is cared for by an unwanted health professional. In an illustrative case, a hospital ethicist in Hawaii recounts the tale of a Korean gentleman who refused life-saving therapy but still wished to remain full code.7 In reconciling this apparent contradiction, the ethicist found that the patient worried that his Japanese physicians were in fact trying to kill him. Only after his care was transferred to non-Japanese physicians did the patient accept treatment and recover from his illness. In another case, a surgeon, fearing that the patient would forego a necessary procedure, acquiesced to a patient’s husband’s request that no black men enter the operating room during his wife’s surgery.8 Physicians have an ethical duty to ensure that patients receive needed care. In the surgeon’s story above, the patient had actually been referred to him by a different surgeon who would not accommodate the request to exclude black men from the operating theater.8 The referring surgeon appropriately fulfilled his duty by helping the patient find a surgeon who would accept her conditions. In health care settings with many clinicians, considering the accommodation question is largely academic; it is a trivial matter to refer the patient elsewhere.
However, when clinicians are scarce as in rural settings or in emergencies, a patient’s affirmative or negative preference may be at odds with his or her clinical interests. If a trauma patient requiring emergency surgery presents to my hospital at 3 AM, I may be the only supervising anesthesiologist present. If I am on call with our black trauma surgeon, and the patient requests no black health care professionals, what course shall we take? Should that patient not undergo surgery? Ethics consultations can be helpful in such situations when time allows, but ultimately, competent patients must be allowed to decide who cares for them and how. Just as we would accept a Jehovah’s Witness’ life-threatening refusal of blood transfusion, so must we respect a patient’s desire for certain care professionals. Faced with this decision, I would comply with the patient’s wishes. To do otherwise would risk committing battery, the act of intentional nonconsensual offensive contact.9 I can only hope that the prospect of irrevocable harm would force an urgent reconsideration of our patient’s prejudices. Does patient-centered care, then, justify tolerating bigotry? In my opinion, yes. I cannot countenance bigotry and other forms of prejudice, but my discomfort with a patient’s beliefs does not trump their right to specify the conditions of their care. It is my hope that by affording all patients with the respect that was so often denied to my forebears, the questions I have considered here will eventually become irrelevant to the practice of medicine.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
4. Karoub J. Some patients won’t see nurses of different race. http://bigstory.ap.org/article/some -patients-wont-see-nurses-different-race. Accessed October 17, 2013.
1. Norris M. For a black doctor, building trust by slowing down. http://www.npr.org/2013/05/01 /178442772/for-a-black-doctor-building-trust-by -slowing-down. Accessed October 17, 2013.
5. Newsroom WNEM. Nurses told not to touch white patient. http://www.wnem.com/story /22911660/nurses-told-not-to-touch-white -patient. Accessed October 17, 2013.
2. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915.
6. American Medical Association. Opinion 9.06. Free choice. Code of Medical Ethics. 2012. http://www.ama-assn.org/ama/pub/physician -resources/medical-ethics/code-medical-ethics /opinion906.page.
7. Kipnis K. Quality care and the wounds of diversity. In: Mappes T, DeGrazia D, eds. Biomedical Ethics. 6th ed. Boston, MA: McGraw-Hill; 2006. 8. Foubister V. Requests by patients can put doctors in ethical bind. Am Med News. 2001;22(January):•. http://business .highbeam.com/137033/article-1G1-70395591 /requests-patients-can-put-doctors-ethical-bind. 9. Legal Information Institute. Battery. August 19, 2010. http://www.law.cornell.edu/wex/battery. Accessed October 17, 2013.
3. Paul-Emile K. Patients' racial preferences and the medical culture of accommodation. UCLA Law Rev. 2012;60(2):462-504.
140
JAMA January 8, 2014 Volume 311, Number 2
Copyright 2014 American Medical Association. All rights reserved.
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