As an intern fulfilling my internal medicine outpatient rotation requirement, I worked in an urgent care walk-in clinic. One afternoon, I entered the waiting room to meet my last patient of the day. He was a 65-year-old white man who was receiving a workup for renal carcinoma.
After cheerfully introducing myself, I heard no response. As I tried to engage him in conversation, he provided very succinct answers to my questions. After I finished obtaining a history, I reviewed the results of a previously ordered imaging study that confirmed the presence of an inoperable malignant tumor with extensive metastasis. I decided to complete my physical examination before informing him of the unfortunate news.
As I lifted his shirt to auscultate his chest, I noticed a portion of a tattoo on his back. It seemed to be some type of 4-legged animal. The lower aspect of this image was so elaborate and full of detail that I became intensely intrigued. I complimented him: "Wow, what a neat tattoo!"
I asked him to help me lift his shirt further. He hesitated and held his hand in a manner that indicated he did not want me to see what had already been unveiled. As I lifted it further, there it was—the 4-legged image was a horse that was supporting a man covered in a white sheet holding a burning torch. I had just complimented my patient on a tattoo of a Ku Klux Klan member mounted on a horse! I felt as if all the oxygen in my body had just been sucked out of me. I was embarrassed, humiliated, and infuriated. I thought, "This is why he was acting so cold toward me." What was even more perplexing was that I did not see it coming. I took a deep breath and impulsively remarked, "Hmm. That's interesting." He replied, "Oh, that's from my younger days when I was young and dumb."
I regained enough composure to finish my physical examination, and then I told him I would be right back and walked out of the room expeditiously in an attempt to conceal the tears welling in my eyes. I managed to avoid crying and presented the case to the attending physician. I later returned to the patient's room and informed him of his diagnosis and poor prognosis. After informing him of his terminal illness, I pondered over how he then perceived the relevance of my skin color.
"You looked unprofessional"
A year later I was working full-time in the field of psychiatry. On the first day of my inpatient rotation at a private hospital I encountered a 70-year-old white woman with severe, refractory major depressive disorder and borderline personality disorder. After I introduced myself as her new physician, she informed me that I was mistaken. She later asked my attending physician if it was necessary for her to have 2 physicians. My attending explained to her that this was a teaching institution and that he would really appreciate it if she cooperated by allowing me to help facilitate her treatment.
She reluctantly agreed; however, she maintained limited interaction with me and said she would wait until morning rounds to fully discuss her concerns or symptoms with my supervisor. Two days later, she was discharged to a nursing home with a one-to-one sitter. Surprisingly, 2 days before the completion of my rotation and during my last call of the month, I learned that she was in the emergency department after making a very serious suicide attempt. She had escaped from her sitter in the nursing home and walked out into traffic. I thought, "Why me? Why on my last call night do I have to see her of all patients?" I walked anxiously into the room and the following exchange took place.
"Where is my doctor?" she asked. "I am not talking to anyone else but my doctor."
"I am the doctor on call for the evening and your doctor is unavailable," I replied.
"Well, I will just wait right here until he can come."
"He will not be in the hospital until tomorrow morning."
"Well, I will just spend the night in the ER then."
Intuitively, I felt that this was the time for me to confront her and uncover whatever issue she had with me. So I replied, "I know that you prefer to have my attending evaluate you. However, I am truly the only person available tonight and it is not feasible for you to spend the night here in this room. I think it is time for us to explore what your issues are with me and what is keeping you from allowing me to help you. Did I do something to offend you?" Her answer was, "Well, when I first saw you I thought you looked unprofessional."
"Oh, really? What was I wearing that day that portrayed an unprofessional appearance?"
"It's not that I don't like black people, but . . ."
At that moment, everything became crystal clear to me. I asked her, "Have you ever had a black physician?"
"Never, never, never."
"I can now understand why this is so hard for you. But tell me, what does that mean for you to have a black physician?"
"Well, it brings about an issue of competence for me."
This statement struck a chord deep within me. It felt more excruciating than the reality of her discrimination. As a member of a minority group, I imagined that I would encounter racism and that subsequently my competence would be in question. However, I did not anticipate or consider that this would potentially occur with the very people I had dedicated my life to serving. I then posed the question, "Do you think that your doctor would have trusted me to be here with you if he didn't feel I was competent?"
"I guess not."
"Well, will you please allow me to evaluate you and admit you into the hospital tonight? I will notify my attending in the morning of your insistence that I no longer be involved in your treatment."
"Okay, that's fine."
Surprisingly, the patient sought me out for help over the next 2 days while I was on service. This by no means suggests that we developed an adequate therapeutic relationship. However, I do believe that something powerful happened when I encouraged her to freely express and explore her prejudiced scrutiny of me.
In retrospect, I have reflected about the alternative responses I could have had to these 2 patients. When scenarios such as these impact you so personally, there is a struggle between the primitive drive to freely express your emotions and the superego-driven wish to react in an honorable manner.
I realize that if I had reacted emotionally I might have perpetuated stereotypes or misconceived notions that these patients had, thus confirming the elderly woman's perceived "unprofessional" image of me. What is the moral of these stories? Hatred, bigotry, prejudice, and ignorance are as ubiquitous in our patients as they are in society at large. The best I can hope for is to take the high road when I meet them on the path to graduation.