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What to do when your patient is racist?

by: Alex Smith, @alexsmithMD

I'd like GeriPal reader's help with an issue that has vexed me since medical school. 

As a third year medical student, I cared for an elderly patient in a residential hospice facility with advanced cancer.  Unable to get up and about without assistance, he complained about feeling "trapped" in his room.  So I got him into the wheelchair and we went outside to enjoy the California sun. 

Several nurses passed by on the other side of the street and my patient made horrible racist remarks about them. 

I froze. 

I didn't know what to do.  I felt terrible that he was saying these things about the nurses.  I was also aware that the nurses could not hear him - we were too far away - and that this man was nearing the end of his life.  Nothing I said was likely to change his perspective or his behavior.  I said nothing.  He died two weeks later.  I've felt bad about that lack of response ever since.

I'd like to write a piece about a better way to approach the racist patient.  While there have been provocative stories in the literature (also here and here), there has been little written in the way of a well thought-out approach to the racist patient.  My early sense is that there is almost always more going on than the racism: PTSD, feeling ignored, pain.  We should explore and respond to the underlying issues first. That can be hard.  Racism pushes buttons like few other issues.

I can use your help.  I'm looking for stories about racist patients you have cared for in geriatrics and palliative care.  My sense is racism is more common in geriatrics and palliative care because (1) our patients are older, and lived in a time before Civil Rights; and (2) racist comments may be an expression of vulnerability and distress.

Racism runs a spectrum, from a Jewish provider and a patient with an antisemitic tattoo, to comments directed at other members of the healthcare team (as in my story above), to comments directed at the provider.  I'm interested in all of these stories.  Please respond with stories in the comments.

Some rules:
(1) Keep it anonymous.  Notice how you couldn't identify the patient in my story, but the essence of the story came across?  Some tricks - change the gender, the setting, the disease, the relationship of the caregiver. 
(2) Stories are most helpful if you share how you responded and why

A final thought. I want to write a paper about how physicians should approach the racist patient.  But my sense is that, despite the influx of foreign medical graduates and increasing diversity of the physician workforce, racist comments directed at non-physician members of the health care team are far more common than comments directed at physicians.  Nurses. Nurses assistants.  I just returned from our nursing home where the nurses and nurses aids related story after story of racist patients.  In our hospital, there is far more diversity among the nurses assistants than the physicians.  They are turning patients, responding to call buttons, asking about pain.  Patients may be reluctant to make the same racist remarks to a physician due to social norms. 

What is the physician's obligation to respond when the racism is directed at other members of the healthcare team?  How should physicians respond when a patient asks not to be cared for by minority providers?

Comments

Anonymous said…
I wonder in this case if we need to consider patient rights. They have cultural rights as well as rights to treatment, etc. These comments are part of the culture they grew up in and still live in. We cannot impose our own cultural understandings on the patients we serve. However, we still need to protect the people who serve so care must be taken to prevent physical and emotional danger. If a caregiver is struggling to care for the patient then we should provide opportunities for them to excuse themselves from this situation and take on a different patient.

There was a patient in my hospital who was very racist towards another color of people. Two different nurses reacted in two different ways. One nurse requested an exchange of patients in order to continue to provide best care which this situation she felt was compromising for her. Another nurse experiencing the same racist comments felt that she could provide best care practices even though these comments were being made and she made the decision to continue working with this patient. Both understood that a patient's rights culturally needed to be protected as well as their own physical and emotional safety. As a support person for the nurses and the patient. I listened to concerns on both sides and continued to watch for emotional health. I didn't encourage the patient's words. I just listened and provided the patient the opportunity to have a right to her own cultural understanding while also giving the caregivers time to speak with me about the difficulties they were having. They both understood that I could not correct the patient's words and that I didn't believe those words. In that case I knew that I did the best care possible to both the patient and the caregivers.
Anonymous said…
I am an RN who spent much of my career caring for hospice patients. I once had a police officer arrive at the home of a black man who had just died on hospice (unfortunately a neighbor called the police) and begin to make racist remarks to an unseen colleague on his cell phone. The middle age man who died from AIDS acquired through IV drug use was a kind hearted man who was greatly loved by his friends and family. I had attended the death and his friends were with him at the end in his run down rental house in a very poor neighborhood. Prior to the officers arrival, the mood in the house had been sad but cohesive and loving. I felt the energy change to hostile and suspicious within minutes as the officer reported the death to his colleague of "just another damn black junkie". I said to the officer ( within hearing of the friends and family) that his job must be very difficult as he had to walk into situations like this one without any knowledge of what the deceased had been like. He didn't get the privilege that I had (a middle age white woman) of getting to know and love the deceased. To all our shock, the officer TEARED UP and acknowledged he was at a great disadvantage. I felt an immediate softening of the attitudes of the observers and of the officer. He stayed until the funeral home staff arrived and helped me to get the body ready for transport. He thanked me later for my insight into his distress yet I barely had said anything.

The lesson I learned is that people may denigrate or lash out at others because they are scared or unsure of themselves. The "other" may be frightening to some people and I now challenge racist comments as non-judgmentally as possible. I say something to the effect that I have NOT found "all blacks to be ignorant, all whites to be superficial, etc". It may not change the mind of the person making the comments but I feel better for clarifying that I have had a different experience.
anonymous said…
I have to disagree that racist thoughts and expressions are a reflection of culture that needs to be respected. As an African American physician I have been subjected to remarks, behavior etc that were clearly racially motivated. Being sick isn't an excuse doesn't mean that I should tolerate it. It may be that some illnesses/medications may disinhibit someone but that does not mean that such behavior should be tolerated. Being terminally ill is not an excuse to just behave whatever way you want. Being racist is not cultural behavior even if you grew up in an area where that was considered 'ok'. It is behavior born out of hate, intolerance and ignorance. It should not be condoned, tolerated or respected like true culturally different behavior. No one has the right to be racist.
Anonymous said…
I agree that racist comments shouldn't be tolerated. I grew up white in a racist southern family and I knew as a child it was wrong and often said so to my parents dismay. I recall being slapped hard by mother when I explained to her that the future would look different when many of us inter-married and we all became a lovely cocoa color and not white or black (I think I was 10 or 11). She informed me I would never be allowed to return home if I married a n...r and I had nothing but disgust even at that young age for her ignorance. Challenge all racist remarks whether they come from family, friends and even dying patients.
Anonymous said…
My parents might be considered racist by some of their comments when they are in the hospital. In their eighties, in a hospital, they say things that they would never had said otherwise (though, as they get older, their social skills are getting worse and I see sides of them otherwise unseen).

Hospital delirium causes hallucinations, and many of those involve the staff that surround them, which are often ethnic. I think some of this feeds their remarks. Once they recover from that delirium, they still believe that parts of that are real. My dad, even years later, cannot be convinced that his hallucinations were not real.

During my mom's last visit (she does have dementia), she made several comments about a physical feature of the face that my mom wanted to touch, much like a child.

I work with large numbers of under-represented youths. I think a lot about issues that they face and the attitudes of others around them. I think it's up to each of us, when these things are said, to address them. Sometimes you don't have to say much, even if it's just to say that you disagree. But I think it's wrong to say nothing.

I think many of the more subtle remarks are more difficult. I don't know where my mom's fascination with the nurse's face came from, unless it was because she was different, and when you feel you have nothing at the time, maybe it's easier to concentrate on what's different.
Alex Smith said…
I just wanted to take a moment to thank all of the commenters on this post for sharing their perspectives and stories.

As these comments remind us, this issue is remarkably complex, and there is no single answer for all situations.
Alex Smith said…
I also want to direct readers attention to another post by an African American female physician caring for a patient with racist tatoos. A remarkably moving story.

http://www.gradydoctor.com/2011/12/sos.html
Jennifer Webster said…
Hello all,

My name is Jennifer Webster and I write for MD News, a magazine for physicians and healthcare executives (www.mdnews.com). I'm working on an article about how physicians and others caregivers deal with patients who are openly racist towards their providers.

If anyone here would care to comment on this topic, from the position of a doctor, nurse, or healthcare administrator, please drop me an email: jwebster (at) truenorthcustom.com.

Thank you so much!
Kerrie Peacock said…
I would definitely agree that racist comments should not be tolerated. But it is hard with older patients who are set in their ways. My grandmother was rude to all the nurses and her reasoning was that she was going to die soon so what was the point of being nice. She was afraid so she took it out on the people around her. They may not truly mean the things they say but are just afraid and letting it out the only way they can think of.

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