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Emergency physicians must learn to understand their prejudices and control them, treating all patients with equal decency

Virtus Probata Florescit

Since the time of John Locke, western liberal views about how government should be run, administrated and judged have fallen into very rigid patterns. We believe, for instance, that freedom is a prized possession. And yet freedom of speech remains a difficult issue. Take, for example, the building of a mosque near ground zero in lower Manhattan. Is the building of that mosque defended by the constitution of the United States? Without question. Is it in good taste? Absolutely not. So how do your resolve an issue where the law says “yes” and public opinion says “no”?

The reason this issue is important for emergency physicians is because the emergency departments in the United States should be respites from political drama. The ED should be the one place in the country where, at any moment day or night, if your momma doesn’t love you and the police don’t want you, you can come and be treated decently. It should be free of political thought.

Now if you believe that the ED is that bastion of neutrality, free of all political bias, I have a bridge in lower Manhattan that heads to Brooklyn that I’d like to sell you. The reality is that politics are everywhere. The question is, how do we rein them in so that we can give out reasonably competent care without letting our innate prejudices control us? Anybody who is reading this column at this moment who believes that they do not have prejudices should just stop reading now. You’re obviously an idiot. Everyone has prejudices, everybody has feelings. We have fat prejudice, thin prejudice, we have where-they-went-to-school prejudice. To think that ethnic prejudices are the only prejudices we carry around is a huge mistake; we have all kinds of forces that push the way we believe and act every single day. The key to being an emergency physician is understanding your own prejudices and controlling them. You have to be able to remind yourself before you walk in an exam room that you do not want any preconceived notions controlling the kind of care that you give. I have had to deal with these scenarios time and time again throughout my career, to varying degrees of success, and I’ve learned a few lessons along the way.

Many years ago I saw a 24-year-old Muslim woman who presented with her husband. She was complaining of lower abdominal pain, but her husband did not want her disrobed, nor did he want a male physician examining her. There was no female physician working at that time and there would not be for several hours. What should you do in this situation? Is there a natural prejudice? Of course there is. I worried that an important medical condition could be missed.

The resolution was relatively simple. I started by pulling the husband outside so I could talk to the patient, which was difficult because she and I had a language barrier. I tried to make her understand that proper examination was a part of the way we arrive at a diagnosis. I warned her and her husband of the possibility of the danger of delayed diagnosis, which they understood. They were also informed that there would be a female physician available in four hours, for whom they were willing to wait. I had to step back, take a deep breath and realize that people come to the emergency department with their own issues and concerns, which must be dealt with patiently. This couple hadn’t come to me for judgment; they came to me for care. Judgment is the province of the Lord, but care has to be given within the context that the patient and family will allow.

We could easily push this scenario one step further: If I had been at a smaller hospital with a more rural community, there may have been no reasonable options but to convince them that examination was required. What then? What if we were dealing with a couple whose culture believed in mutilating female genitalia to suppress sexual response? Is this a freedom of religion question? I have experienced this personally – and I called the police – but it is not viewed the same way by every culture. As these matters get more complicated, we bring in even more of our ethnic baggage and we run the risk of letting culture push medicine ahead of science.

My American prejudices were challenged on a different occasion with an American Gypsy family. It was important to the Gypsies that everyone be present in the exam room. Why they actually needed to have 14 people in the room for a pelvic exam (unless it was to steal stuff) was beyond me. Eventually we were able to get everyone into the room that the woman requested, and I was able to keep the comments and general yelling down to a roar during the pelvic exam. Old women screamed that I was hurting her while young men said that I should be doing it more. I completed the exam and the diagnosis of ectopic pregnancy was made, but it was not before certain emotions had been expressed on both sides of the glass.

In another simple case of prejudice, a nurse informed me that my next patient was to be an old Korean woman. I naturally asked for the nurses to call up to anesthesia to have a Korean nurse anesthetist come down to act as translator. I walked in the room with the Korean nurse anesthetist and asked the Korean woman if she had any pain. Before the Korean nurse anesthetist could translate, the woman looked at me and said “No, not at all.” I had made the assumption that since she was old and Korean that she did not speak English. We have to take people one at a time and assess what their real needs are.

These are different concepts than we are used to. What we learn in medical school is science; what we learn in practice is what is achievable under certain circumstances. Part of this will always be ethnic limitations. I can’t help being male and I can’t help being white. Heck, I am the ultimate of white. If you look in the dictionary under “white man” you will see my picture. There is nothing I can do about that except recognize the sensitivities that need to be dealt with.

When we look at the literature, we see some seemingly damning studies on ethnic disparities in treatment. There is no question, for example, that Hispanics receive less pain medication than Caucasians in the emergency department. Yet even this study is not entirely clear on the subject of discrimination – even Hispanic doctors give Hispanic patients less pain medication. What is the reason for this? I’m not sure. But before we start flagellating ourselves, understand that there is a cultural mountain which will take time to resolve and may never be completely ascended. EMTALA requires everyone to be seen – only our hearts require that it be done with respect and decency. You don’t have to love everyone that comes in but they do have to be given an equal quality of care.

The issue becomes even broader when you consider the verbal statements we make in the ED. In the case of “Keyishian vs The Board of Regents at the University of the State of New York” the U.S. Supreme Court took strides towards freedom of speech in the academic realm.

Does this mean that if you are an academic doctor you have a right to refer to a patient as fat, lazy and stupid? Your freedom of speech does not mean that you ought to be speaking at any given moment. For the physician who feels required to give patients lectures on morality, basic hygiene and maintenance of the height-weight ratio, just understand that the hospital administration can also exercise their rights in helping you find new employment.

We would like to think that this type of prejudice does not go on in the department, but it does every day. It is so easy to pick out a black/white situation or, heaven forbid, a Jewish/Muslim situation, just understand that prejudice comes in many different colors, and bigots come in all shapes and sizes. The best thing we can do is step outside the room, take a deep breath, and say, “May my words be kind today, because I may have to eat them tomorrow.”
 



 

 

Comments   

# Mark Jaben 2010-12-08 17:37
Greg,
Well said.
But you could go further and discuss the preconceived notions we bring about each other, our institutions and administrators
We all believe we know exactly why things just won't work. But do we?

You can't stop these assumptions. They are deep seated and firmly ingrained, the result of what our unconscious brain does, modifying genetic predispositions with our experiences. They often guide us very well, except where they don't.

But as you say, we need to learn these circummstances and have strategies to act to curb these powerful urges. We need to be willing to test these assumptions and demonstrate whether they can be extrapolated to the exact new situation you are confronting.

Maybe, it's not just about ethnic issues, but at the very core of why we can't get improvements done and why 'nothing ever changes.'
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# MS3, MBAAnel Alexis 2011-02-14 23:32
Hi Greg! I enjoy reading your articles.
The US is more than ever a multicultural society. I believe all physicians, especially emergency physicians who are most likely to have the first contact with any patient, must be culturally competent. The physician's knowledge about other cultures can only help both parties: less frustrations for US, satisfaction for the patient.
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