I’m waiting for the day when a patient tells me, “I don’t want you to take care of me” solely on the basis of my race. As a black physician, it is unfortunately a very real scenario. This was a common narrative for my grandmother, who was a nurse, and for my mother, who is a pediatrician.
I grew up hearing stories from my grandmother about working as a nurse in East Texas. She had many patients who did not want her to provide care to them because she was black. Many patients who initially refused her care specifically asked for her after they saw the compassionate care she provided other patients. It was refreshing to hear that excellent patient care can sometimes override a patient’s beliefs about race.
My mother, who is a highly respected pediatrician, has discussed numerous examples of parents requesting other providers, the most recent example occurring just last year. The grandparents of a newborn asked my mother if the white nurse practitioner who was working with her that day could immediately assume care of their grandchild; my mother reluctantly agreed. The grandparents subsequently told the nurse practitioner that they would not be returning to the clinic.
I am certain there have been instances where patients preferred not to see me based on my race. Rather than the patient abruptly leaving or directly requesting another physician, their preference probably manifested in a moment of silence as I entered the exam room, not scheduling a follow-up appointment, or writing a negative Press Ganey score. I have been fortunate not to have heard the words “I want to see another physician” … yet.
I have had several black patients tell me “it’s so nice to have a black doctor.” I realize that as a black male physician I am unfortunately an uncommon sight. Hearing this recurring statement also makes me wonder if in general white patients prefer white doctors, Asians prefer Asian doctors, and if Hispanics prefer Hispanic doctors, etc. Studies have found that some patients do seek care from physicians of concordant race based on their personal preferences.1
Patient preferences affect patients’ trust in their physician to a certain extent. For example, I have Spanish-speaking patients tell me that they have more confianza, or trust, in me as a physician because I speak Spanish. It is well known that trusting your physician positively affects the patient-physician relationship and leads to better patient outcomes.2 Certain patient requests are considered acceptable, such as females requesting female physicians for Pap exams. However, patient preferences and accommodation based solely on bigotry are not.3 Ultimately, I believe that providing high quality care can overcome most barriers and gain patients’ trust just like it did for my grandmother decades earlier. We are frequently oblivious to our patients’ beliefs on race unless explicitly expressed.
A few years ago I saw a white patient who presented to clinic with acute shoulder pain. He was very pleasant and the history portion of the encounter was uneventful. I asked him to remove his shirt in order to examine his shoulder and I immediately noticed a large swastika tattooed on his posterior shoulder. My millisecond of hesitation must have obliged him to offer an explanation. “I’m sorry,” he said “when I was in jail I had to pick sides in order to fit in, I regret getting it.” I told the patient that an explanation was not necessary, “I’m not here to judge, I’m here to provide good medical care.” The rest of the visit was unremarkable and I never saw him again.
We all carry potentially controversial beliefs, some are easily seen on the surface (or just underneath our clothing), and others are deeper. Physicians are not immune to these conscious and unconscious biases and their deleterious impact on patient care. When I see patients who were incarcerated I have to make a concerted effort to quell my bias due to my experience of being robbed at gunpoint. Recognizing our personal biases and leaving them at the exam room door is ideal, but the reality is blurry. I felt the need to be exceedingly thorough with the patient with shoulder pain to make sure my aversion toward the swastika (and probably subconsciously him) did not negatively impact his care.
Biases can negatively impact patient care, but they can also curb professional development for physicians of color. I am keenly aware of the wage gap between black male physicians making almost $65,000 less than their white male counterparts.4 One my black female colleagues was paid significantly less than her cofaculty for 5 years before she realized the pay discrepancy. I once asked for a raise and my supervisor asked me, “Why are you being so uppity?” I’m not sure if he knew that the term “uppity” had racial connotations, but as a young minority faculty I strive to remember my value and expect to be compensated to that value.
I was recently interviewed for a survey about the path of black physicians into medicine. The interviewer asked me, “Do you feel that your race has negatively impacted your career?” After careful thought, I responded with a surprising “no.” With all the subtle and obvious forms of bias and outright racism in this country, I honestly do not believe my race has visibly affected my career trajectory. I am aware that I am an outlier in this belief based on the many incidents I have heard from black colleagues.
When the day comes that a patient refuses to see me, although foreseeable, it will still be humiliating, painful, and scarring.5 I must balance respect for the patients’ wishes without reinforcing the notion that bigotry is ok. Race is a huge and sometimes obtuse issue, but we as physicians can do our part in reducing the negative effects caused by race-induced biases. There have been great strides in race relations since my grandmother was nurse in the 1960s. An ongoing conversation about race is necessary for those advancements to continue.