Be not a spectator: don’t stand for this

14 Jan

During our “Preparation for Practice” module we had two role-play sessions on advanced communication skills; one on breaking bad news and one on dealing with difficult patients. During the second of these sessions I was struck by the attitudes of some of my colleagues, who seemed to think that in the course of our future work as doctors we are expected to put up with seemingly no end of abuse and prejudice, for a variety of stupid reasons.

Here are some of the role-play scenarios from the session, followed by what will hopefully be an understandable rant.

scenario 1: racism

 patient: So whereabouts in the world are you from then?

 student: I’m from around here, I live in Newcastle.

 patient: No, I mean where are you from?

 student: Oh, well originally I’m from Durham.

 patient: You’re not, you can’t be, how long have you lived in England?

 student: I’ve always lived in England.

 patient: Well, you don’t look like you’re English *scoffs incredulously*

This scenario involved a white patient and a non-white student, who I thought handled the episode fantastically well considering what was being said to her. She managed to stay calm throughout the consultation – whilst at least half of her audience sat seething with rage – got a decent history and even attempted to challenge the patient’s consistently offensive behaviour a few minutes later:

 student: Since you hurt your shoulder, have you been able to – 

 patient: Are you sure you’re English? You definitely don’t look it.

 student: Yes, I’m sure. Not all English people look the same, you know.

 patient: Yes they do. They all look white, anyway.

 student: No, they don’t. I think English people can look very different from each other, but it doesn’t mean they’re not English.

 patient: Nonsense *huffs and puffs indignantly*

As possibly one of the most sickeningly pale individuals in a country classically famed for its lack of sunlight, racism isn’t something I’ve ever had to deal with first-hand. The closest I’ve ever got to becoming actively discriminated against was when some girls at school started to bully me for being a “goth bitch” (pale skin, dark hair, liked rock music – it was pretty much inevitable but that doesn’t make it right), and I’ll never forget how unpleasant that was. I can only imagine how utterly awful it must feel to be dismissed or insulted on the basis of something so senselessly petty as your nationality or your accent.

I think this situation highlights very well the problems faced by doctors working in a multicultural society, where unfortunately a proportion of the elderly population and a minority group of dickhead white supremacists haven’t quite figured out yet that a person’s creed, colour or country of origin has absolutely no bearing on their worth as a human being. As inhabitants of the 21st century, it is our responsibility to aid them in figuring this out, and in doing so to steer the course of humanity, however minutely, in the direction of a better future.

scenario 2: sexism

student: So can you tell me a little about what’s been going on?

patient: Well to start with, let me just say you’ve got two things going for you, you’re white and you’re male, which is good to see. Not like a lot of the so-called “doctors” gallivanting around here. So for that reason I’ll tell you…

There was also a similar situation involving a female student, where the patient basically started challenging her right to work as a doctor – or indeed to work in any profession – and telling her off for not being “in her place” at home baking muffins and raising offspring. She also said something about women’s brains being smaller than men’s. I forget the exact dialogue, but you get the gist of it.

Now I’m no feminist – those of you who know me will be aware that I see it as no more than a glorified form of catty chauvinism – but I think that sentiments like these are just as abhorrent as those in the first scenario.

As a woman training to be a doctor, I’d need at least 50 fingers to count the number of times a lovely elderly patient I’ve been clerking, examining, taking blood from or just chatting to has assumed I’m a nurse or a nursing student, despite the fact I’ve introduced myself as a medical student or “student doctor”, and often done doctory things involving percussion notes, stethoscopes and tendon hammers. I don’t normally mind this, as back in their day female doctors were a genuine rarity, but sometimes when I correct them there’s an expression of patronising disbelief on their faces that winds me up a little. Thankfully I’ve never encountered a situation like the one above just yet, fingers crossed I never will…

scenario 3: ageism

student: I’d like to examine your shoulder, if that’s OK with you?

patient: Well who are you, what do you know? You don’t look old enough to be in this job anyway.

student: I can assure you I’m fully qualified, like I said before I’m one of the junior doctors working with the team today.

patient: Haha, don’t be silly, you can’t have been doing this long. How long have you been a doctor for?

Admittedly, as an F1 or F2 doctor his answer would be a year or a few months, but that’s not the point. He has undertaken at least five years of training and has been certified as a competent and capable medical practitioner, albeit one with a lot left to learn. Handling a minor shoulder sprain would be well within the range of his hypothetical abilities – he wouldn’t be able to surgically repair a shoulder fracture or reattach an arm, but that’s irrelevant as nobody would expect him to.

A situation similar to this one happened to Suzi on series 1 of Junior Doctors – if I remember rightly the patient sent her away, essentially saying she wasn’t qualified to be speaking to him. You can only imagine how after five or six years of hard work at medical school, being unfairly dismissed in this way would make you feel like absolute shit.

scenario 4: anger & aggression

The last scenario involved the father of a child who had been misdiagnosed by members of the paediatric A&E team. He had presented with symptoms of very early appendicitis – essentially a temparature, an upset tummy and non-specific abdominal pain – but was diagnosed with viral gastroenteritis and sent home. Later that evening his appendix ruptured and he was rushed to the nearest hospital, where it was removed. A couple of days later, understandably rather cross at what had happened, his father returned to the department to demand an explanation.

The role-player was fantastic: he walked in virtually smouldering with fury, stood gripping the back of a chair and addressed the junior doctor in a loud, confrontational but not-quite-shouting Geordie voice, which made him seem incredibly threatening.

 parent: (having explained the situation at length and become increasingly more irate) … and I want to know why YOUSE, who are supposed to be DOCTAHS, didn’t realise what was gannin’ on! He could’ve DIED, man! D’yez not even care?! 

 student: I can understand why you’re so upset, and I’d be more than happy to answer your questions about what happened while he was here, and why we made the decisions we made. Would you like to sit down and we could talk about it in more detail?

The gentleman didn’t respond to the offer of sitting down, and if anything became even more frightening and aggressive in demanding the explanations he had already been openly offered. The student ultimately defused the situation by saying:

 student: I’m sorry sir, I can see you’re extremely upset but I have to say I’m feeling a little threatened by you at the moment. I think we’d both be a lot more comfortable if you took a seat so I could explain everything properly. 

This stopped the man in his tracks, and after he’d sat down the student proceeded to give an excellent and detailed explanation of what had happened and why the diagnosis had been missed, which the man seemed happy with. The way in which he had defused the situation caused some controversy though, as the lady leading the seminar was of the opinion that telling someone you felt threatened  by them when they were quite definitely behaving threateningly towards you was frightfully rude.

Several others in the group (myself included) disagreed with her. I think that if someone is being overly aggressive to the point where you actually feel unsafe in their presence, you have a right to voice the fact that you feel threatened by them. In a lot of cases, particularly when dealing with an anxious relative or angry parent, the individual might not actually realise that their overwhelming emotions are being conveyed so strongly, and will probably tone things down as a result as long as you state your feelings diplomatically.

A report published in 2010 found that 32% of NHS staff had experienced verbal aggression from a patient, and 18% had experienced it from a member of the public whilst at work. In terms of actual physical assault, 5% of staff had been assaulted by a patient, and 1% by a member of the public who was not a patient. The frequency of physical assaults on NHS staff has actually increased since 2004. There is therefore a genuine risk of aggression or actual physical harm to all hospital employees. I find this appalling, and believe that doctors and other members of staff have an unquestionable right to stand up for themselves if they feel themselves to be in a hostile situation.

Why I won’t stand for this

After the role-play scenarios, we had an opportunity for group discussion about what we had seen. After a slightly heated debate about the handling of the fourth scenario, we moved on to talk about appropriate responses to prejudice and discrimination by patients. The discussion quickly escalated into a state of conflict, as some members of the group began to express quite pathetically outrageous platitudes about why it was “wrong” to challenge a racist patient. Examples of these included:

  • It is wrong to challenge a racist patient because you have to respect patients’ beliefs. – Voltaire said, “I may disapprove of what you say, but I will defend to the death your right to say it“. You can respect someone’s right to hold a particular belief as much as you like, but this does not mean that you in any way agree with or respect the belief itself, and if it is immoral or illegal or poses a risk of harm to yourself or others, you are most definitely under no obligation whatsoever to treat it with anything less than contempt.
  • It is wrong to challenge a racist patient because you would be using your position of power to impose your own beliefs upon them. – or would you instead be challenging their beliefs as is your right to do so as a fellow human being? Challenging someone’s offensive statements only constitutes expressing your disagreement with them; there would be no need to explain or justify or enforce your own personal beliefs at any time.
  • It is wrong to challenge a racist patient because that would be moralising a medical situation – what is the point of  learning all this medical ethics if it is then considered wrong to ‘moralise’ in your everyday practice? The perception amongst those upholding this opinion seems to be that it is only doctors who are expected to behave in a morally acceptable manner, whilst on the other side of the equation patients can do or say whatever they like without any ramifications. A study of Norfolk NHS found that a percentage of staff had been upset by discriminatory comments concerning race, gender, religion, sexual orientation and disabilities. These comments had come from both fellow staff members, and patients or members of the public. According to some of my colleagues, the staff should be subject to moral judgement for their behaviour, but the patients should not, because this would be ‘disrespecting their beliefs’ or ‘moralising the situation’.
  • It is wrong to challenge a racist patient because it would go against the principle of do no harm. – this assumes that your challenge would somehow upset the patient deeply enough to cause genuine harm; if one handled the situation diplomatically there should be little reason for this to occur. Taking this standpoint also depends on whether or not you view the enormous harm done by prejudice and discrimination across the globe as dismissable.
  • It is wrong to challenge a racist patient because that would be unprofessional.” – I agree that if a doctor were to go around belligerently lecturing every patient who ever expressed a mildly prejudiced belief, this would be unprofessional. This would be the equivalent of me kicking off at every sweet and harmless old man who ever assumed I was a nurse because I had breasts, which would clearly be pointless. The beliefs I would propose to challenge would be openly held, openly voiced and offensive prejudices, which were persistently voiced despite attempts to ignore them or move the conversation away from the subject.  This could involve, for example, rants about “pakis”, “niggers”, “chinks”, “queers” or “spastics”, or personal insults towards other patients or members of staff. In these situations, your professional responsibility to respect your patient’s beliefs would undeniably be outweighed by your professional and personal responsibilities to society. By “challenge”, I don’t mean publicly indicting them as evil or branding them across the forehead with hot irons, I mean simply saying “I don’t think that’s relevant right now“, “I’d rather you didn’t talk about that“, or “I’d appreciate if you kept those opinions to yourself“. The fact remains that prejudice is not seen as acceptable behaviour by society and as such is against the law. The government actively encourages all individuals to challenge discrimination and racist behaviour. The Hippocratic Oath – the rather outdated code of medical morality lazily invoked by my colleagues previously as stating “do no harm” – also states that “I will remember that I remain a member of society with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm“. This implies that you are expected to continue to fulfil your role as a member of society alongside your additional responsibilities as a doctor. The GMC may state that under normal circumstances it is not acceptable to challenge patients’ beliefs – which I absolutely agree with, as it could cause distress and undermine the therapeutic relationship – but I think that in the circumstances described above, it would be inappropriate not to.
  • It is wrong to challenge a racist patient. It is your responsibility as a doctor to instead elicit the ideas, concerns and expectations that lie behind the patient’s beliefs. – I’m not even going to comment on this one as it’s just such complete and utter simpering bollocks.

Duties of a doctor?

Overriding all of these statements was the idea that “a doctor still has a duty to treat a patient, no matter what they say or do“. I disagree with this: the patient most certainly has an inalienable right to receive medical treatment from the health service, but it does not have to be provided by the doctor in question. Unless the situation were an absolute emergency, the patient could be handed over or referred to a different doctor. The GMC indirectly provides guidance for situations like these, as they essentially fulfil the criteria for  ‘conscientious objection’. As long as you “made the care of the patient your first concern” (paragraph 17), and your personal objections to their views did not “prejudice your assessment of their clinical needs, or delay or restrict their access to care” (paragraph 18) during the transfer of the patient to another doctor, you would be acting within the GMC guidance. Personally, I think I would be more than happy to expedite the fulfilment of these two conditions just to get the patient out of my sight.

Whilst the GMC states that it is not normally acceptable to “seek to opt out of treating a particular patient because of your personal beliefs about them” (paragraph 25), I think that in circumstances of extreme discrimination – e.g. a patient hurling racist abuse at an Indian doctor or persistently expressing offensive beliefs despite being asked not to – it would be best for both parties if the patient were moved to someone else’s care. The doctor would be removed from a distressing situation which could affect their emotional wellbeing and ability to care for other patients, and the patient would be removed from the care of a doctor whose anger and resentment engendered by their behaviour could compromise their care. You would have to be an absolute saint – or an emotionally sterile robot – to continue to treat a patient who had been personally abusive towards you or a member of your team without being emotionally compromised in some way. By arranging alternative care, you would actually be trying to do what was best for the patient.

Ultimately, doctors do not sign away their rights to avoid or object to prejudice, discrimination or aggression when they enter a hospital. There is a “no tolerance” policy towards violence against NHS staff, and logically this should extend to cover verbal abuse and prejudice as well. It is everyone’s responsibility to challenge potentially harmful beliefs when we encounter them, whether this occurs on the street, in our own homes or in our professional environment.

By allowing truly hateful and harmful beliefs to go unchallenged, you are passively becoming an apologist for racism, sexism and other forms of abhorrent prejudice. It appears that many of my colleagues are happy to take this standpoint, valuing political correctness and the avoidance of conversational awkwardness over the defence of the dignity and basic rights of their fellow human beings. I, however, most certainly am not.

.

“Never be a spectator to unfairness or stupidity.”

Christopher Hitchens

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To finish, here are some clips of ethnic minorities being absolutely bloody brilliant:

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6 Responses to “Be not a spectator: don’t stand for this”

  1. Maevea Maverick Digital Presence January 14, 2012 at 3:01 pm #

    General, stupid people are inherently racist, I see your predicament, But as a general rule personality saids it all. If you are a healer and self governing pioneer of medicine your ability to treat people should not adhere to attitudes and your beliefs towards any such patient regardless of how they present them selves to you. Most patients are rude and abnoxious and expect medical treatment no matter what. And if you can disect a human body then you can treat a human body regardless (no matter what) . If you are finding during your intern that your fellow collegues are concerned about your ability to function in a crunch, get your ethics and moralisation in check, as I would be concerned if my professor read this blog! And or any fellow medical employers! As its show lack of a diginified will, and the questionable status of reasonability to logical thinking.

    A. MD. MM.

    • laurajaynewatson January 14, 2012 at 3:46 pm #

      Hi,

      I’d just like to clear up that I wasn’t accusing “stupid people” of being inherently racist or vice versa – I see racism and prejudice as an issue completely separate from intellectual capacity.

      I feel that I am more than capable of rising above my own personal feelings in order to deal with people who are “rude” or “obnoxious”, and under normal circumstances there is absolutely no way I would allow those personal feelings to alter my management of an individual patient, as this would be unfair and unprofessional. During the past two years of clinical experience I have had the opportunity to develop the capacity to emotionally detach myself from clinical situations to an appropriate extent, and it’s very rare that I find myself ever becoming emotionally involved in a particular situation. On the occasions that this has happened, the patient in question had been verbally abusive to me on a personal level, but I still managed to treat them as I would any other patient. Admittedly as a medical student my involvement in their clinical care was minimal, but I still had to maintain a professional rapport with the individual in question, and this is something I felt I did more than satisfactorily on each occasion.

      I realise and accept that dealing with difficult patients is likely to be something I will have to do on a regular basis once I start work, and I have no qualms with it as I perceive the overriding benefits of providing care to someone in need as being unquestionably far greater than the stress of having to deal with a few moments of upset or irritation.

      What I’m specifically referring to in this post – which I perhaps should have made more clear – is direct verbal or physical abuse directed at staff, which I think is a much more extreme problem than simply dealing with someone who’s “a bit difficult”, and something that a lot of doctors would struggle to deal with if they or a member of their team were ever subjected to it. Of course if there were no choice in the matter, I would not hesitate to provide the patient with the necessary care and attention they needed, no matter how appalling or extreme their words or actions were. However, if the option were available, I think it would be prudent to refer them to someone else’s care, both for my own benefit and, more importantly, for the patients benefit, in order to ensure they received the best possible clinical care.

      I also think that verbal or physical abuse of other patients, or the open expression of racist or sexist beliefs in the public arena of a ward or clinic environment – which is the other issue I’ve tried to tackle here – would be something that would require some form of diplomatic intervention in order to protect others from harm.

      A lot of what I have said is purely a hypothetical dissection of what we’ve been told at medical school and how it would apply to extreme situations like those I’ve mentioned, as I was quite surprised that some of my colleagues said they would do nothing to even attempt to prevent the expression of illegal and discriminatory remarks in their professional environment.

      Thanks for your comment, I appreciate hearing someone else’s views on the subject.
      Laura

  2. Elise December 5, 2012 at 11:22 am #

    Oh my gosh… I love you, Definitely following this blog. Hah! Found it while searching for a prolapsed uterus (I’m in nursing school… taking my OB finals today) I work as a patient care technician (nurses aid) at a nearby hospital that is in a VERY multi-racial area. And I have met PLENTY of racists. I am white, but I all too often get old farts who complain about all of the Indian and African immigrants who are nurses and doctors to me. “Why aren’t there any white people” they say. I so want to ask them how many nurses and doctors that they shat out of their vajayjay. *Answer,,, Probably none… They have art and drama majors with no jobs that still live at home with their grandkids… Some cultures are just more hard-working and realistic about post-grad job prospects. I wouldn’t count white people as a part of that group anymore.

    • unbridledoptimist December 10, 2012 at 7:05 pm #

      Thanks for the comment, I’m glad you feel the same way! Hope the final exams went well xxx

Trackbacks/Pingbacks

  1. Palliative Acupressure « Pedanto returns - January 14, 2012

    […] Once again I’m very aware that my medical degree has not had much emphasis on the minor things like science, reason or how the world actually works. In fact for a science-based degree there appears to have been very little assessment of whether something is believeable. The following phrases are seemingly unknown by the majority of Newcastle graduates: confirmation bias, cognitive dissonance, the file draw effect. Instead we are taught to unerringly elicit and respect patients’ “Ideas Concerns and Expectations” without any capacity to challenge them if they are either repulsive or stupid, as apparently the most vital part of making a patient better is their fondness for you – for more information see here. […]

  2. Hooray! Other people won’t stand for this either! « Unbridled Optimist - July 23, 2012

    […] I would post this as a follow-up to my not-quite-so recent rant about racism and other forms of prejudice, as it cheered me up […]

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